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General NPI Number Information
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NPI Number | 1366589780
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Entity Type | Organization
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Legal Business Name | MARTA JACENYIK LLC
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 03/03/2014
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Provider Practice Location Address
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Address Line | 3759 BENGAL RD
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City | GULF BREEZE
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State | FL
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Zip | 32563-3454
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Country | US
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Telephone | 850-934-9866
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1171
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City | GULF BREEZE
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State | FL
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Zip | 32562-1171
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARTA JACENYIK
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Credential |
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Telephone | 850-934-9866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | ME67496
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License Number State | FL
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