Provider Demographics
NPI:1700656782
Name:EGLAUS, JENCY KERMONSTHA
Entity Type:Individual
Prefix:
First Name:JENCY
Middle Name:KERMONSTHA
Last Name:EGLAUS
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 1:6241SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-1173
Mailing Address - Country:US
Mailing Address - Phone:954-825-1662
Mailing Address - Fax:
Practice Address - Street 1:2615 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-1173
Practice Address - Country:US
Practice Address - Phone:195-482-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician