MEDICARE: JACOREA BREON TAYLOR

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	251C00000X	Developmentally Disabled Services Day Training Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1467067538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOREA BREON TAYLOR

Provider Business Mailing Address
First Line	:	1727 PARK OAK DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-1777
Country	:	US
Telephone Number	:	713-483-8261
Fax Number	:

Provider Business Practice Location Address
First Line	:	1727 PARK OAK DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-1777
Country	:	US
Telephone Number	:	713-483-8261
Fax Number	:

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

Provider Enumeration Date	:	09/15/2020
Last Update Date	:	09/15/2020

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