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General NPI Number Information
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NPI Number | 1366796476
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Entity Type | Individual
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Provider Name | JERRY ELLIOTT WILCOXON MACCCSLP
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Gender | Male
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 11/09/2015
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Provider Practice Location Address
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Address Line | 4048 GRANDE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32250-3021
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Country | US
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Telephone | 904-566-6031
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Fax |
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Provider Business Mailing Address
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Address Line | 4048 GRANDE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32250-3021
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Country | US
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Telephone | 904-566-6031
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA 10677
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License Number State | FL
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