Healthcare Provider Details

I. General information

NPI: 1295178580
Provider Name (Legal Business Name): JACOB RANDALL LASSITER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 REDSTONE AVE W STE 470
CRESTVIEW FL
32536-6457
US

IV. Provider business mailing address

550 REDSTONE AVE W STE 470
CRESTVIEW FL
32536-6457
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-2229
  • Fax:
Mailing address:
  • Phone: 850-689-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24652
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMD.34009
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME140756
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: