Healthcare Provider Details

I. General information

NPI: 1124616420
Provider Name (Legal Business Name): JESSICA FERNANDEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 08/29/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 SE 6TH ST
FORT LAUDERDALE FL
33301-3407
US

IV. Provider business mailing address

624 SE 6TH ST
FORT LAUDERDALE FL
33301-3407
US

V. Phone/Fax

Practice location:
  • Phone: 954-826-0926
  • Fax:
Mailing address:
  • Phone: 954-262-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116598
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: