MEDICARE: MR. JEAN T. PROULX

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1053679365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEAN T. PROULX

Provider Business Mailing Address
First Line	:	3132 BEACH BOULEVARD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-3710
Country	:	US
Telephone Number	:	904-398-7118
Fax Number	:	904-398-7114

Provider Business Practice Location Address
First Line	:	3132 BEACH BOULEVARD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-3710
Country	:	US
Telephone Number	:	904-398-7118
Fax Number	:

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

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	04/25/2012

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Directions to “ MR. JEAN T. PROULX ” Practice Location

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