Healthcare Provider Details

I. General information

NPI: 1538124706
Provider Name (Legal Business Name): FELICIA ANN JEROME D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 US 1 S STE 200
ST AUGUSTINE FL
32086-5786
US

IV. Provider business mailing address

1955 US 1 S STE 200
ST AUGUSTINE FL
32086-5786
US

V. Phone/Fax

Practice location:
  • Phone: 904-494-2840
  • Fax: 904-829-6174
Mailing address:
  • Phone: 904-494-2840
  • Fax: 904-829-6174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7594
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: