Healthcare Provider Details

I. General information

NPI: 1740836329
Provider Name (Legal Business Name): JILANN B DOUCETTE RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2019
Last Update Date: 08/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FARRADAY LN UNIT F
PALM COAST FL
32137-3853
US

IV. Provider business mailing address

4 CEDARFIELD CT
PALM COAST FL
32137-8950
US

V. Phone/Fax

Practice location:
  • Phone: 386-523-6672
  • Fax:
Mailing address:
  • Phone: 386-523-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7404
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number7404
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number7404
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number7404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: