Provider Demographics
NPI:1396023131
Name:JACKSONVILLE DENTAL AND MEDICAL TEMP AGENCY
Entity Type:Organization
Organization Name:JACKSONVILLE DENTAL AND MEDICAL TEMP AGENCY
Other - Org Name:JAX DENTAL AND MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-803-0617
Mailing Address - Street 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:BUILDING 500 SUITE 518
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-268-9988
Mailing Address - Fax:904-268-9922
Practice Address - Street 1:421 LABARRE CT
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4024
Practice Address - Country:US
Practice Address - Phone:904-803-0617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health