Healthcare Provider Details

I. General information

NPI: 1225973274
Provider Name (Legal Business Name): JESSICA EZELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 COPPOLA DR
MOUNT DORA FL
32757-8068
US

IV. Provider business mailing address

4607 COPPOLA DR
MOUNT DORA FL
32757-8068
US

V. Phone/Fax

Practice location:
  • Phone: 912-665-3714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License NumberCRT80851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: