Healthcare Provider Details

I. General information

NPI: 1053155010
Provider Name (Legal Business Name): JENNIFER COUGHLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER SEVIER

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E SAMPLE RD
DEERFIELD BEACH FL
33064-3502
US

IV. Provider business mailing address

921 GREENBRIAR AVE
DAVIE FL
33325-6338
US

V. Phone/Fax

Practice location:
  • Phone: 954-941-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.450544
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9618853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: