Healthcare Provider Details

I. General information

NPI: 1952952087
Provider Name (Legal Business Name): JEROME TIMOTHY FOUNTAIN III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17670 NW 78TH AVE
HIALEAH FL
33015-3664
US

IV. Provider business mailing address

11650 NW 29TH MNR
SUNRISE FL
33323-1649
US

V. Phone/Fax

Practice location:
  • Phone: 305-512-5757
  • Fax:
Mailing address:
  • Phone: 239-867-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA17452
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: