Provider Demographics
NPI:1942622998
Name:ALBATROSOV, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ALBATROSOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4387
Mailing Address - Country:US
Mailing Address - Phone:386-562-8213
Mailing Address - Fax:
Practice Address - Street 1:119 S PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4387
Practice Address - Country:US
Practice Address - Phone:386-562-8213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALPP-29291174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN