Basic Information
| Provider Information | |||||||||
| NPI: | 1295268209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERWIN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12655 COLLIER BLVD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341164005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 305657 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PO098 | 01 | FL | MEDICARE | OTHER | 115112400 | 05 | FL | MEDICAID |