Healthcare Provider Details

I. General information

NPI: 1710746789
Provider Name (Legal Business Name): STORM JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 VONDERBURG DR STE 201
BRANDON FL
33511-5900
US

IV. Provider business mailing address

602 VONDERBURG DR STE 201
BRANDON FL
33511-5900
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-6644
  • Fax: 813-654-6644
Mailing address:
  • Phone: 813-653-6644
  • Fax: 813-654-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: