Provider Demographics
NPI:1689186124
Name:POWERS, JEANETTE ELLA
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ELLA
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:ELLA
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5690 W ATLANTIC AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8218
Mailing Address - Country:US
Mailing Address - Phone:708-289-5341
Mailing Address - Fax:
Practice Address - Street 1:5690 W ATLANTIC AVE APT 304
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8218
Practice Address - Country:US
Practice Address - Phone:708-289-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW445166302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization