Provider Demographics
NPI:1578143715
Name:TERRELL, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:TERRELL
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 1:4395 LAKE ASHBY RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-5204
Mailing Address - Country:US
Mailing Address - Phone:386-847-9321
Mailing Address - Fax:
Practice Address - Street 1:4395 LAKE ASHBY RD
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-5204
Practice Address - Country:US
Practice Address - Phone:386-847-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program