Healthcare Provider Details

I. General information

NPI: 1962232140
Provider Name (Legal Business Name): JACKIE SEKUNDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2024
Last Update Date: 08/03/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 BLAKEMORE DR
PALM COAST FL
32137-7336
US

IV. Provider business mailing address

9 BLAKEMORE DR
PALM COAST FL
32137-7336
US

V. Phone/Fax

Practice location:
  • Phone: 973-713-8051
  • Fax:
Mailing address:
  • Phone: 973-713-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: