Provider Demographics
NPI:1538667936
Name:GARCIA FERNANDEZ, JESUS MANUEL
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:MANUEL
Last Name:GARCIA FERNANDEZ
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 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:2775 LAKE ALFRED RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1432
Practice Address - Country:US
Practice Address - Phone:863-291-4590
Practice Address - Fax:863-508-6503
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL11009754363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1043635972Medicaid