MEDICARE: MR. JONATHAN L DETLEFS EXEMPT APP.

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	372500000X	Chore Provider	DL190541	SD

General Provider Information

NPI Number	:	1649118175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN L DETLEFS EXEMPT APP.

Provider Business Mailing Address
First Line	:	13876 ATLANTIC BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-3239
Country	:	US
Telephone Number	:	904-620-0000
Fax Number	:	904-274-0111

Provider Business Practice Location Address
First Line	:	13876 ATLANTIC BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-3239
Country	:	US
Telephone Number	:	904-620-0000
Fax Number	:	904-274-0111

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

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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