Provider Demographics
NPI:1346820743
Name:RILEY, JAHVONTAE
Entity Type:Individual
Prefix:
First Name:JAHVONTAE
Middle Name:
Last Name:RILEY
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 1:4316 MARINERS COVE CT APT 104
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9014
Mailing Address - Country:US
Mailing Address - Phone:352-364-6422
Mailing Address - Fax:
Practice Address - Street 1:4316 MARINERS COVE CT APT 104
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9014
Practice Address - Country:US
Practice Address - Phone:352-364-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker