Provider Demographics
NPI:1790385144
Name:BERTEAU, JEFFREY PAUL
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:BERTEAU
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 1:464016 STATE ROAD 200
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6339
Mailing Address - Country:US
Mailing Address - Phone:904-261-9846
Mailing Address - Fax:904-261-9846
Practice Address - Street 1:464016 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6339
Practice Address - Country:US
Practice Address - Phone:904-261-9846
Practice Address - Fax:904-261-9846
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS24485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist