Jackson Reef

Primary specialty

Health Service Clinic/CenterTaxonomy code 261QH0100X

Legal business name

JACKSON REEF

Practice address

495 S Nova Rd Ste 101a
Ormond Beach, FL 32174-8444

Phone

(386) 487-4673

Fax

(855) 829-5770

NPI assigned

Jul 17, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. William Louis Self, DNP, CRNA

Title

Owner

Phone

(386) 487-4673

Specialties & licenses 1

Addresses

Other names 1

• Life Is Ketaful Doing business as

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1563321600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1596758400000",
    "number": "1396398608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "495 S NOVA RD STE 101A",
            "city": "ORMOND BEACH",
            "state": "FL",
            "postal_code": "321748444",
            "telephone_number": "386-487-4673",
            "fax_number": "855-829-5770"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "495 S NOVA RD STE 101A",
            "city": "ORMOND BEACH",
            "state": "FL",
            "postal_code": "321748444",
            "telephone_number": "386-487-4673",
            "fax_number": "855-829-5770"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "851 Dunlawton Ave Ste 103",
            "address_purpose": "LOCATION",
            "city": "Port Orange",
            "state": "FL",
            "postal_code": "321274234",
            "country_code": "US",
            "telephone_number": "386-487-4673",
            "fax_number": "855-829-5779",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "JACKSON REEF",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-07-17",
        "last_updated": "2020-08-07",
        "certification_date": "2020-08-07",
        "status": "A",
        "authorized_official_last_name": "SELF",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "LOUIS",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "386-487-4673",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DNP, CRNA"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "https://intakeq.com/api/v1/",
            "affiliation": "N",
            "endpointDescription": "IntakeQ API is composed of HTTP endpoints that can be reached through a REST API.",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "851 Dunlawton Ave Ste 103",
            "city": "Port Orange",
            "state": "FL",
            "country_code": "US",
            "postal_code": "321274234",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Life Is Ketaful",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Health Service Clinic/Center in Ormond Beach, FL
• Providers in Ormond Beach, FL by specialty
• Health Service Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.