Healthcare Provider Details

I. General information

NPI: 1003481680
Provider Name (Legal Business Name): JASIE BEHRENS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N FLORIDA AVE
LAKELAND FL
33805-3109
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

V. Phone/Fax

Practice location:
  • Phone: 863-904-6201
  • Fax: 866-264-8519
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114380
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9114380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: