MEDICARE: MRS. JENIFER OULBOUB PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9111108	FL

General Provider Information

NPI Number	:	1295222537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENIFER OULBOUB PA-C

Provider Business Mailing Address
First Line	:	2827 NW 7TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-7633
Country	:	US
Telephone Number	:	954-789-3202
Fax Number	:

Provider Business Practice Location Address
First Line	:	6448 PEMBROKE RD
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33023-2138
Country	:	US
Telephone Number	:	954-799-0543
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2018
Last Update Date	:	02/17/2021

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