Healthcare Provider Details

I. General information

NPI: 1811376601
Provider Name (Legal Business Name): JESSICA LYNN DOUGLAS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 SW STONEGATE TER STE 103
LAKE CITY FL
32024-3457
US

IV. Provider business mailing address

104 WOODMONT BLVD STE 500
NASHVILLE TN
37205-2245
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-1655
  • Fax: 386-628-9231
Mailing address:
  • Phone: 559-475-4151
  • Fax: 559-421-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9310684
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9310684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: