Healthcare Provider Details

I. General information

NPI: 1093364051
Provider Name (Legal Business Name): JENNA LEA MARSHALL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 BARTRAM PARK BLVD
JACKSONVILLE FL
32258-5212
US

IV. Provider business mailing address

145 CLOVERBANK RD
ST AUGUSTINE FL
32092-9360
US

V. Phone/Fax

Practice location:
  • Phone: 904-402-8346
  • Fax:
Mailing address:
  • Phone: 352-224-8951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: