Healthcare Provider Details

I. General information

NPI: 1114563301
Provider Name (Legal Business Name): JESSICA CORNELIA WOODALL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4866 BIG ISLAND DR UNIT 5
JACKSONVILLE FL
32246-5301
US

IV. Provider business mailing address

2411 COVINGTON CREEK CIR W
JACKSONVILLE FL
32224-1181
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-0652
  • Fax:
Mailing address:
  • Phone: 954-303-0419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015255
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number9435365
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: