Provider Demographics
NPI:1750260568
Name:JEAN, EZECHIEL
Entity type:Individual
Prefix:
First Name:EZECHIEL
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 1:51 ALEGRO DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32409-1745
Mailing Address - Country:US
Mailing Address - Phone:561-513-7382
Mailing Address - Fax:850-257-8096
Practice Address - Street 1:51 ALEGRO DR
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:FL
Practice Address - Zip Code:32409-1745
Practice Address - Country:US
Practice Address - Phone:561-513-7382
Practice Address - Fax:850-257-8096
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907145311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home