MEDICARE: JERRY JACOB RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	9454105	FL

General Provider Information

NPI Number	:	1023799525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY JACOB RN

Provider Business Mailing Address
First Line	:	10058 NW 49TH PL
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33076-2418
Country	:	US
Telephone Number	:	954-895-9745
Fax Number	:

Provider Business Practice Location Address
First Line	:	10058 NW 49TH PL
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33076-2418
Country	:	US
Telephone Number	:	954-895-9745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	07/27/2023

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