Provider Demographics
NPI:1750626172
Name:MEDDERS, JADE MARIE (EMT-B)
Entity type:Individual
Prefix:MRS
First Name:JADE
Middle Name:MARIE
Last Name:MEDDERS
Suffix:
Gender:F
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 291938
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-1938
Mailing Address - Country:US
Mailing Address - Phone:386-562-4070
Mailing Address - Fax:386-760-0532
Practice Address - Street 1:725 DUNLAWTON AVE
Practice Address - Street 2:#291938
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-7001
Practice Address - Country:US
Practice Address - Phone:386-562-4070
Practice Address - Fax:386-492-6941
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLEMT509305146N00000X
DC280101040340690183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No183700000XPharmacy Service ProvidersPharmacy Technician