Healthcare Provider Details

I. General information

NPI: 1235458084
Provider Name (Legal Business Name): JPFO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 N OAK ST
VALDOSTA GA
31602-2533
US

IV. Provider business mailing address

2410 N OAK ST
VALDOSTA GA
31602-2533
US

V. Phone/Fax

Practice location:
  • Phone: 229-293-8337
  • Fax: 229-293-8338
Mailing address:
  • Phone: 229-293-8337
  • Fax: 229-293-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001085
License Number StateGA

VIII. Authorized Official

Name: DR. JEFFERSON PEARCE FUTCH
Title or Position: OWNER
Credential: D,P.M.
Phone: 229-293-8337