Healthcare Provider Details

I. General information

NPI: 1124963608
Provider Name (Legal Business Name): JACOB PRINCE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 NW ALBRITTON LN
LAKE CITY FL
32055-4451
US

IV. Provider business mailing address

23476 NW 186TH AVE
HIGH SPRINGS FL
32643-0673
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-4020
  • Fax: 386-752-9143
Mailing address:
  • Phone: 386-454-0698
  • Fax: 386-454-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11048113
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9366609
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: