Healthcare Provider Details

I. General information

NPI: 1114572567
Provider Name (Legal Business Name): HANNAH JACON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD STE 4102
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100265
GAINESVILLE FL
32610-0265
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0239
  • Fax: 352-265-1107
Mailing address:
  • Phone: 352-265-0239
  • Fax: 352-265-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: