Healthcare Provider Details

I. General information

NPI: 1487098620
Provider Name (Legal Business Name): KJG-S. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 JAZZ DR
PANAMA CITY FL
32405-4906
US

IV. Provider business mailing address

105 JAZZ DR
PANAMA CITY FL
32405-4906
US

V. Phone/Fax

Practice location:
  • Phone: 850-522-9719
  • Fax: 850-522-9718
Mailing address:
  • Phone: 850-522-9719
  • Fax: 850-522-9718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11162
License Number StateFL

VIII. Authorized Official

Name: KELLY SHELTON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 850-522-9719