Basic Information
| Provider Information | |||||||||
| NPI: | 1386635548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN: CREDENTIAL DEPT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 3280 N MCMULLEN BOOTH RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272161141 | ||||||||
| FaxNumber: | 7277966459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | OS6862 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | OS6861 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 261639400 | 05 | FL | MEDICAID |