Healthcare Provider Details

I. General information

NPI: 1902027717
Provider Name (Legal Business Name): JESSE QUINN OWENS BADGER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/19/2020
Certification Date: 01/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8823 SAN JOSE BLVD STE 209
JACKSONVILLE FL
32217-4288
US

IV. Provider business mailing address

8823 SAN JOSE BLVD STE 209
JACKSONVILLE FL
32217-4288
US

V. Phone/Fax

Practice location:
  • Phone: 904-404-7044
  • Fax: 904-329-2303
Mailing address:
  • Phone: 904-404-7044
  • Fax: 904-329-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: