MEDICARE: JAKARTA WASHINGTON

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	376J00000X	Homemaker

General Provider Information

NPI Number	:	1588493019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKARTA WASHINGTON

Provider Business Mailing Address
First Line	:	13507 BEAUMONT AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-2420
Country	:	US
Telephone Number	:	216-554-9572
Fax Number	:

Provider Business Practice Location Address
First Line	:	13507 BEAUMONT AVE
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-2420
Country	:	US
Telephone Number	:	216-554-9572
Fax Number	:

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

Provider Enumeration Date	:	08/01/2024
Last Update Date	:	08/01/2024

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Directions to “ JAKARTA WASHINGTON ” Practice Location

Language	Start Address	Practice Location

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