Provider Demographics
NPI:1306468392
Name:CLERSAINVILLE, JEAN A
Entity type:Individual
Prefix:MR
First Name:JEAN
Middle Name:A
Last Name:CLERSAINVILLE
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 1:3615 SW 52ND AVE APT B203
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 SW 52ND AVE APT B203
Practice Address - Street 2:
Practice Address - City:PEMBROKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-6942
Practice Address - Country:US
Practice Address - Phone:754-703-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC462461752650172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL842464757OtherC-CLASS TRANSPORT