Healthcare Provider Details

I. General information

NPI: 1992634612
Provider Name (Legal Business Name): JAXOMS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 STIRLING RD STE 300
COOPER CITY FL
33024-8066
US

IV. Provider business mailing address

9900 STIRLING RD STE 300
COOPER CITY FL
33024-8066
US

V. Phone/Fax

Practice location:
  • Phone: 402-805-4516
  • Fax:
Mailing address:
  • Phone: 402-805-4516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JENN HERITAGE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 402-805-4516