Provider Demographics
NPI:1760053441
Name:J 4 DYNASTY, LLC
Entity Type:Organization
Organization Name:J 4 DYNASTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MGR
Authorized Official - Prefix:
Authorized Official - First Name:LATORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:813-606-5010
Mailing Address - Street 1:10150 HIGHLAND MANOR DR STE 200-106
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9713
Mailing Address - Country:US
Mailing Address - Phone:813-606-5010
Mailing Address - Fax:877-228-8577
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 200-106
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9713
Practice Address - Country:US
Practice Address - Phone:813-606-5010
Practice Address - Fax:877-228-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty