Provider Demographics
NPI:1639987399
Name:JEAN, JACKY
Entity type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:JEAN
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 1:166 REDWING CT
Mailing Address - Street 2:
Mailing Address - City:POINCIANA
Mailing Address - State:FL
Mailing Address - Zip Code:34759-5110
Mailing Address - Country:US
Mailing Address - Phone:407-795-6748
Mailing Address - Fax:
Practice Address - Street 1:166 REDWING CT
Practice Address - Street 2:
Practice Address - City:POINCIANA
Practice Address - State:FL
Practice Address - Zip Code:34759-5110
Practice Address - Country:US
Practice Address - Phone:407-795-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant