Healthcare Provider Details

I. General information

NPI: 1437730207
Provider Name (Legal Business Name): JACLYN B ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN B KURTTILA

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 RIGGINS RD
TALLAHASSEE FL
32308-5318
US

IV. Provider business mailing address

PO BOX 13859
TALLAHASSEE FL
32317-3859
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-4134
  • Fax: 850-942-4112
Mailing address:
  • Phone: 850-877-4134
  • Fax: 850-942-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME182606
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME182606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: