Healthcare Provider Details

I. General information

NPI: 1669421889
Provider Name (Legal Business Name): JOHN W JEPMA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 02/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N CAUSEWAY
NEW SMYRNA BEACH FL
32169-5303
US

IV. Provider business mailing address

161 N CAUSEWAY
NEW SMYRNA BEACH FL
32169-5303
US

V. Phone/Fax

Practice location:
  • Phone: 386-424-1584
  • Fax: 386-410-4800
Mailing address:
  • Phone: 386-424-1584
  • Fax: 386-410-4800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number222975
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: