Provider Demographics
NPI:1205403870
Name:POWELL, JEMEL ANTONIO
Entity Type:Individual
Prefix:
First Name:JEMEL
Middle Name:ANTONIO
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 W 28TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-4012
Mailing Address - Country:US
Mailing Address - Phone:904-576-5756
Mailing Address - Fax:
Practice Address - Street 1:1130 W 28TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-4012
Practice Address - Country:US
Practice Address - Phone:904-576-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide