Healthcare Provider Details

I. General information

NPI: 1144054545
Provider Name (Legal Business Name): JENLEE LIVING FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16661 CARLTON POND ST
WIMAUMA FL
33598-2443
US

IV. Provider business mailing address

16661 CARLTON POND ST
WIMAUMA FL
33598-2443
US

V. Phone/Fax

Practice location:
  • Phone: 813-524-6736
  • Fax: 813-479-6931
Mailing address:
  • Phone: 813-524-6736
  • Fax: 813-479-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BLACK
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-524-6736