Healthcare Provider Details

I. General information

NPI: 1265989487
Provider Name (Legal Business Name): JESSICA JEFFRIES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 10/29/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E COUNTY ROAD 540A
LAKELAND FL
33813-3825
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-7267
  • Fax: 866-264-8519
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMED-PAC-LIC-50812
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: