MEDICARE: JESSICA KUILAN LCSW

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	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker	SW13911	FL

General Provider Information

NPI Number	:	1427506658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KUILAN LCSW

Provider Business Mailing Address
First Line	:	5011 GATE PARKWAY BLDG 100 SUITE 100
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0830
Country	:	US
Telephone Number	:	305-439-6969
Fax Number	:	305-230-7616

Provider Business Practice Location Address
First Line	:	5011 GATE PARKWAY
Second Line	:	BLDG 100, SUITE 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256
Country	:	US
Telephone Number	:	305-783-3991
Fax Number	:	305-230-7616

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

Provider Enumeration Date	:	09/16/2016
Last Update Date	:	08/26/2020

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