Provider Demographics
NPI:1346703774
Name:GRANT, JAHPHET Y
Entity type:Individual
Prefix:
First Name:JAHPHET
Middle Name:Y
Last Name:GRANT
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 1:2252 WRIGHT ST # A
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-4345
Mailing Address - Country:US
Mailing Address - Phone:239-935-9247
Mailing Address - Fax:239-466-0142
Practice Address - Street 1:2252 WRIGHT ST # A
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4345
Practice Address - Country:US
Practice Address - Phone:239-935-9247
Practice Address - Fax:239-466-0142
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311ZA0620X
FL6906925310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home