Healthcare Provider Details

I. General information

NPI: 1558966754
Provider Name (Legal Business Name): JAKLEEN MOUSSA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4744 S FLORIDA AVE
LAKELAND FL
33813-2181
US

IV. Provider business mailing address

511 VINTAGE WAY
BRANDON FL
33511-6365
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-1226
  • Fax:
Mailing address:
  • Phone: 813-758-3337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number22849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: