Healthcare Provider Details

I. General information

NPI: 1619675311
Provider Name (Legal Business Name): JENNY C JEUDI FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 LANTANA RD STE 100
LAKE WORTH FL
33462-1304
US

IV. Provider business mailing address

5416 SANDBIRCH WAY
LAKE WORTH FL
33463-7201
US

V. Phone/Fax

Practice location:
  • Phone: 561-965-1864
  • Fax:
Mailing address:
  • Phone: 516-495-0552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022001273
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11024928
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: