Healthcare Provider Details

I. General information

NPI: 1124569215
Provider Name (Legal Business Name): CASSAUNDRA THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 BELFORT RD STE 3075
JACKSONVILLE FL
32216-1475
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-5785
  • Fax: 904-296-4786
Mailing address:
  • Phone: 904-450-6017
  • Fax: 904-450-6041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS16518
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: