Healthcare Provider Details

I. General information

NPI: 1184071730
Provider Name (Legal Business Name): BRUCE BRIAN BEARDSLEY JR. ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12058 SAN JOSE BLVD STE 1003
JACKSONVILLE FL
32223-8667
US

IV. Provider business mailing address

5623 ORTEGA FARMS BLVD
JACKSONVILLE FL
32244-2335
US

V. Phone/Fax

Practice location:
  • Phone: 904-321-9875
  • Fax: 904-321-9890
Mailing address:
  • Phone: 904-994-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9273193
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9273193
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: