Healthcare Provider Details

I. General information

NPI: 1326604596
Provider Name (Legal Business Name): JESSICA L MILLARD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 MAR WALT DR UNIT 220
FORT WALTON BEACH FL
32547-6661
US

IV. Provider business mailing address

1032 MAR WALT DR UNIT 220
FORT WALTON BEACH FL
32547-6661
US

V. Phone/Fax

Practice location:
  • Phone: 850-374-9610
  • Fax: 850-374-9611
Mailing address:
  • Phone: 850-374-9610
  • Fax: 850-374-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberOS23209
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL82180
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number95422
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS23209
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: