Healthcare Provider Details

I. General information

NPI: 1003286824
Provider Name (Legal Business Name): JEFFREY LUDAN VONGJESDA M.S., APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 PHILIPS HWY STE 34
JACKSONVILLE FL
32207-6840
US

IV. Provider business mailing address

3728 PHILIPS HWY STE 34
JACKSONVILLE FL
32207-6840
US

V. Phone/Fax

Practice location:
  • Phone: 904-399-2766
  • Fax: 904-549-8300
Mailing address:
  • Phone: 904-399-2766
  • Fax: 904-549-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9278630
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number60962308
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007934
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number817161
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9278630
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN9278630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: