Provider Demographics
NPI:1376396564
Name:FORDHAM, JAJUAN MONDREESE
Entity Type:Individual
Prefix:
First Name:JAJUAN
Middle Name:MONDREESE
Last Name:FORDHAM
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 1:5805 RENAULT DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1390
Mailing Address - Country:US
Mailing Address - Phone:904-962-1491
Mailing Address - Fax:
Practice Address - Street 1:5805 RENAULT DR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-1390
Practice Address - Country:US
Practice Address - Phone:904-962-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF635433781060343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)