Healthcare Provider Details

I. General information

NPI: 1083539100
Provider Name (Legal Business Name): JADA RYAN CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E DIXIE AVE
LEESBURG FL
34748-5925
US

IV. Provider business mailing address

6317 DOMENICO CT
GROVELAND FL
34736-2771
US

V. Phone/Fax

Practice location:
  • Phone: 353-323-5762
  • Fax:
Mailing address:
  • Phone: 660-322-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9122264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: