MEDICARE: JESSICA SUSAN PACKWOOD P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9104743	FL

General Provider Information

NPI Number	:	1184931974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SUSAN PACKWOOD P.A.

Provider Business Mailing Address
First Line	:	1720 S ORANGE AVE
Second Line	:	STE 500
City	:	ORLANDO
State	:	FL
Zip	:	32806-2945
Country	:	US
Telephone Number	:	407-426-9693
Fax Number	:	407-426-9694

Provider Business Practice Location Address
First Line	:	1720 S ORANGE AVE
Second Line	:	STE 500
City	:	ORLANDO
State	:	FL
Zip	:	32806-2945
Country	:	US
Telephone Number	:	407-426-9693
Fax Number	:	407-426-9694

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2010
Last Update Date	:	10/07/2011

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