MEDICARE: JETIA LASONJA SCALES AGNP-C

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	363LA2200X	Adult Health Nurse Practitioner	11036888	FL
2	363L00000X	Nurse Practitioner	11036888	FL

General Provider Information

NPI Number	:	1740098946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JETIA LASONJA SCALES AGNP-C

Provider Business Mailing Address
First Line	:	8613 OLD KINGS RD S STE 602
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4863
Country	:	US
Telephone Number	:	904-504-5225
Fax Number	:

Provider Business Practice Location Address
First Line	:	8613 OLD KINGS RD S STE 602
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4863
Country	:	US
Telephone Number	:	904-504-5225
Fax Number	:

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

Provider Enumeration Date	:	12/20/2024
Last Update Date	:	03/22/2025

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