Provider Demographics
NPI:1558966754
Name:MOUSSA, JAKLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:JAKLEEN
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 VINTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6365
Mailing Address - Country:US
Mailing Address - Phone:813-758-3337
Mailing Address - Fax:
Practice Address - Street 1:4744 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2181
Practice Address - Country:US
Practice Address - Phone:863-644-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22849124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist