Provider Demographics
NPI:1982131975
Name:GREENFIELD, JEROME
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:GREENFIELD
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 1:13464 YELLOW BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-3803
Mailing Address - Country:US
Mailing Address - Phone:904-601-8846
Mailing Address - Fax:
Practice Address - Street 1:13464 YELLOW BLUFF RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-3803
Practice Address - Country:US
Practice Address - Phone:904-601-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG651439774020372600000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG651-439-77-402-0Medicaid