Healthcare Provider Details

I. General information

NPI: 1861529505
Provider Name (Legal Business Name): JACQUES HOWARD AMOLE DNP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SAN SEBASTIAN WAY
ST. AUGUSTINE FL
32084
US

IV. Provider business mailing address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

V. Phone/Fax

Practice location:
  • Phone: 904-209-6234
  • Fax:
Mailing address:
  • Phone: 386-236-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1084092
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: