Provider Demographics
NPI:1821690926
Name:MOBLEY, JEROME
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:MOBLEY
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 1:1402 ROBIN CT
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3130
Mailing Address - Country:US
Mailing Address - Phone:407-252-4242
Mailing Address - Fax:
Practice Address - Street 1:1402 ROBIN CT
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3130
Practice Address - Country:US
Practice Address - Phone:407-252-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA80266225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist