Healthcare Provider Details

I. General information

NPI: 1376963561
Provider Name (Legal Business Name): JAZMIN SERRA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2014
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 INTERNATIONAL PKWY STE 100
LAKE MARY FL
32746-5057
US

IV. Provider business mailing address

160 INTERNATIONAL PKWY STE 100
LAKE MARY FL
32746-5057
US

V. Phone/Fax

Practice location:
  • Phone: 321-775-5685
  • Fax: 407-386-3056
Mailing address:
  • Phone: 321-775-5685
  • Fax: 407-650-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number233395
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number233395
License Number StateFL

VIII. Authorized Official

Name: DR. JAZMIN SERRA
Title or Position: ADMINISTRATOR
Credential: PHD
Phone: 321-775-5685