Healthcare Provider Details

I. General information

NPI: 1457812471
Provider Name (Legal Business Name): JESSICA LEIGH WARRICK-IMRISEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR STE 1130
JACKSONVILLE FL
32207-8331
US

IV. Provider business mailing address

841 PRUDENTIAL DR STE 1400
JACKSONVILLE FL
32207-8364
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-4199
  • Fax:
Mailing address:
  • Phone: 904-396-5682
  • Fax:

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 Code208000000X
TaxonomyPediatrics Physician
License NumberME155397
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: