MEDICARE: JEFF JACQMEIN MD,PA

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	207Q00000X	Family Medicine Physician	ME71303	FL

General Provider Information

NPI Number	:	1306147590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFF JACQMEIN MD,PA

Provider Business Mailing Address
First Line	:	3872 SAN JOSE PARK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4613
Country	:	US
Telephone Number	:	904-731-0304
Fax Number	:	904-732-2251

Provider Business Practice Location Address
First Line	:	3872 SAN JOSE PARK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4613
Country	:	US
Telephone Number	:	904-731-0304
Fax Number	:	904-732-2251

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JUDY ANNE NICKELS
Credential	:
Telephone Number	:	904-731-0304

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/08/2010

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