Healthcare Provider Details

I. General information

NPI: 1205174695
Provider Name (Legal Business Name): JACKSONVILLE PHYSICAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2013
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7860 GATE PKWY STE 106
JACKSONVILLE FL
32256-7280
US

IV. Provider business mailing address

7860 GATE PKWY STE 106
JACKSONVILLE FL
32256-7280
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-2703
  • Fax: 904-619-2837
Mailing address:
  • Phone: 904-619-2703
  • Fax: 904-619-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME88018
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9278608
License Number StateFL

VIII. Authorized Official

Name: DR. JEREMIAH W. CARLSON
Title or Position: OWNER
Credential:
Phone: 904-619-2703