Healthcare Provider Details

I. General information

NPI: 1245703297
Provider Name (Legal Business Name): JESSICA LEIGH LOWTHER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

2135 SEMINOLE RD
ATLANTIC BEACH FL
32233-5921
US

V. Phone/Fax

Practice location:
  • Phone: 904-999-2802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number122224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: