Healthcare Provider Details

I. General information

NPI: 1952955627
Provider Name (Legal Business Name): B JAZZY SALON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5116 GATE PKWY APT 5111
JACKSONVILLE FL
32256-0265
US

IV. Provider business mailing address

5116 GATE PKWY APT 5111
JACKSONVILLE FL
32256-0265
US

V. Phone/Fax

Practice location:
  • Phone: 904-716-9432
  • Fax:
Mailing address:
  • Phone: 904-716-9432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. CARLISE YVETTE CHARLOT
Title or Position: OWNER/STYLIST PRESIDENT
Credential: LIC COSMETOLOGIST
Phone: 904-716-9432