=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568160026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE JEZREEL COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3921 HAWKS CT
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33331-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-551-6972
-----------------------------------------------------
Fax | 954-385-1019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3921 HAWKS CT
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33331-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-551-6972
-----------------------------------------------------
Fax | 954-385-1019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER ROSE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 954-551-6972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------