Provider Demographics
NPI:1669947495
Name:NIMMO, JADE MARIE
Entity type:Individual
Prefix:MS
First Name:JADE
Middle Name:MARIE
Last Name:NIMMO
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 1:494 CLERMONT AVE S
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4337
Mailing Address - Country:US
Mailing Address - Phone:786-909-9029
Mailing Address - Fax:
Practice Address - Street 1:494 CLERMONT AVE S
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4337
Practice Address - Country:US
Practice Address - Phone:786-909-9029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL730396Medicaid