1922029560 NPI number — MRS. JENNIFFER SUE FERGUSON PAC

Table of content: MRS. JENNIFFER SUE FERGUSON PAC (NPI 1922029560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922029560 NPI number — MRS. JENNIFFER SUE FERGUSON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
JENNIFFER
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELWELL
Provider Other First Name:
JENNIFFER
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922029560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 E DIXIE AVE
Provider Second Line Business Mailing Address:
PLAZA 901
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748-5998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-728-2404
Provider Business Mailing Address Fax Number:
352-787-7401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E DIXIE AVE
Provider Second Line Business Practice Location Address:
PLAZA 901
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-5998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-728-2404
Provider Business Practice Location Address Fax Number:
352-787-7401
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9103323 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 292263100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com