Healthcare Provider Details

I. General information

NPI: 1871977173
Provider Name (Legal Business Name): PHILIP FRANK ALAIN JESSEN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 09/25/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MAR WALT DRIVE INTERNAL MEDICINE DEPARTMENT
FORT WALTON BEACH FL
32547-6707
US

IV. Provider business mailing address

1005 MAR WALT DRIVE INTERNAL MEDICINE
FORT WALTON BEACH FL
32547-6707
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-8202
  • Fax: 850-862-6148
Mailing address:
  • Phone: 850-863-8202
  • Fax: 850-862-6148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN3175792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: