Healthcare Provider Details

I. General information

NPI: 1245178854
Provider Name (Legal Business Name): JAERINE ROA SUPERALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 WELLS RD
ORANGE PARK FL
32073-2969
US

IV. Provider business mailing address

7960 MERCHANTS WAY APT 6205
JACKSONVILLE FL
32222-2950
US

V. Phone/Fax

Practice location:
  • Phone: 877-823-4283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: