Provider Demographics
NPI:1003369588
Name:JAHNKE, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JAHNKE
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 1:6535 CORSICA BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4226
Mailing Address - Country:US
Mailing Address - Phone:321-355-0088
Mailing Address - Fax:
Practice Address - Street 1:6535 CORSICA BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4226
Practice Address - Country:US
Practice Address - Phone:321-355-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor