Healthcare Provider Details

I. General information

NPI: 1205469491
Provider Name (Legal Business Name): JARED CHRISTOPHER HANSEN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 STADIUM RD
DAYTONA BEACH FL
32114-2400
US

IV. Provider business mailing address

1820 LEGENDS LN APT 4202
DAYTONA BEACH FL
32114-0008
US

V. Phone/Fax

Practice location:
  • Phone: 386-254-1149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11006186
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11006186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: