Provider Demographics
NPI:1639607989
Name:HALL, JEANELLA ALLS
Entity Type:Individual
Prefix:
First Name:JEANELLA
Middle Name:ALLS
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 DEWEY JOHNSON WAY
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:FL
Mailing Address - Zip Code:32332-2311
Mailing Address - Country:US
Mailing Address - Phone:850-556-7404
Mailing Address - Fax:850-627-1065
Practice Address - Street 1:865 DEWEY JOHNSON WAY
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:FL
Practice Address - Zip Code:32332-2311
Practice Address - Country:US
Practice Address - Phone:850-556-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL671397Medicaid
FLH400421799190OtherDRIVER LICENSE