Healthcare Provider Details

I. General information

NPI: 1376092809
Provider Name (Legal Business Name): JACK FACUNDUS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 W WARREN AVE STE 100
LONGWOOD FL
32750-4036
US

IV. Provider business mailing address

5151 ADANSON ST
ORLANDO FL
32804-1317
US

V. Phone/Fax

Practice location:
  • Phone: 321-999-9617
  • Fax:
Mailing address:
  • Phone: 407-875-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2824142
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number090740-23
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN2824142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: