Provider Demographics
NPI:1336740851
Name:COULTER, JANELLE MARIE-SIMONE
Entity Type:Individual
Prefix:MS
First Name:JANELLE
Middle Name:MARIE-SIMONE
Last Name:COULTER
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 1:165 WELLS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3036
Mailing Address - Country:US
Mailing Address - Phone:904-269-3522
Mailing Address - Fax:904-621-9339
Practice Address - Street 1:165 WELLS RD STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3036
Practice Address - Country:US
Practice Address - Phone:904-269-3522
Practice Address - Fax:904-621-9339
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist