Provider Demographics
NPI:1760120471
Name:JONES, TAYLOR MAE (STUDENT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MAE
Last Name:JONES
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8917 256TH TRL
Mailing Address - Street 2:
Mailing Address - City:O BRIEN
Mailing Address - State:FL
Mailing Address - Zip Code:32071-3944
Mailing Address - Country:US
Mailing Address - Phone:386-266-6124
Mailing Address - Fax:
Practice Address - Street 1:17924 SE US-19
Practice Address - Street 2:
Practice Address - City:CROSS CITY
Practice Address - State:FL
Practice Address - Zip Code:32628
Practice Address - Country:US
Practice Address - Phone:352-541-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL579065146N00000X
FLAL66042255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic