Healthcare Provider Details

I. General information

NPI: 1487396925
Provider Name (Legal Business Name): JESSICA CANOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W 8TH ST
JACKSONVILLE FL
32209-6533
US

IV. Provider business mailing address

580 W 8TH ST TOWER 1, 9TH FLOOR
JACKSONVILLE FL
32209-6533
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-1022
  • Fax: 904-244-9789
Mailing address:
  • Phone: 904-383-1022
  • Fax: 904-244-9789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: