Provider Demographics
NPI:1861950032
Name:TELFAIR, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:TELFAIR
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 1:2120 PRESTON LN # 34746
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-0018
Mailing Address - Country:US
Mailing Address - Phone:727-492-3685
Mailing Address - Fax:
Practice Address - Street 1:2120 PRESTON LN # 34746
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-0018
Practice Address - Country:US
Practice Address - Phone:727-492-3685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372500000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider