Healthcare Provider Details

I. General information

NPI: 1518402767
Provider Name (Legal Business Name): JACQUELYN O'DONNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2016
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 NIRA ST
JACKSONVILLE FL
32207-8652
US

IV. Provider business mailing address

225 WATER ST STE 1500
JACKSONVILLE FL
32202-5145
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-4991
  • Fax: 904-384-3613
Mailing address:
  • Phone: 904-387-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9110096
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: