Healthcare Provider Details

I. General information

NPI: 1376212944
Provider Name (Legal Business Name): JADE TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 OLD SAINT AUGUSTINE RD
JACKSONVILLE FL
32258-2460
US

IV. Provider business mailing address

24314 GOLD CHEYENNE WAY
KATY TX
77493-3912
US

V. Phone/Fax

Practice location:
  • Phone: 904-271-6000
  • Fax:
Mailing address:
  • Phone: 281-757-2281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number772917
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: