Provider Demographics
NPI:1912587825
Name:JADE CLINIC FAMILY AND WELLNESS CENTER CORP
Entity type:Organization
Organization Name:JADE CLINIC FAMILY AND WELLNESS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAMERA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-475-0034
Mailing Address - Street 1:2665 CLEVELAND AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-5850
Mailing Address - Country:US
Mailing Address - Phone:239-839-1950
Mailing Address - Fax:239-236-1665
Practice Address - Street 1:2665 CLEVELAND AVE STE 208
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5850
Practice Address - Country:US
Practice Address - Phone:239-839-1950
Practice Address - Fax:239-236-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center