Healthcare Provider Details

I. General information

NPI: 1902144140
Provider Name (Legal Business Name): JBRC MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 NE JENSEN BEACH BLVD
JENSEN BEACH FL
34957-7234
US

IV. Provider business mailing address

1802 NE JENSEN BEACH BLVD
JENSEN BEACH FL
34957-7234
US

V. Phone/Fax

Practice location:
  • Phone: 772-252-1235
  • Fax: 772-252-1236
Mailing address:
  • Phone: 772-252-1235
  • Fax: 772-252-1236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 1330
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA 55754
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberME61588
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9104027
License Number StateFL

VIII. Authorized Official

Name: CHRISTOPHER HALL
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 772-261-3422