MEDICARE: MR. JHON WENDY JACQUES SR.

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1578274288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JHON WENDY JACQUES SR.

Provider Business Mailing Address
First Line	:	4635 EMERALD VIS APT C217
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-7238
Country	:	US
Telephone Number	:	954-795-0387
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 EMERALD VIS APT C217
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-7238
Country	:	US
Telephone Number	:	954-795-0387
Fax Number	:

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

Provider Enumeration Date	:	12/13/2022
Last Update Date	:	12/13/2022

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