Healthcare Provider Details

I. General information

NPI: 1851743504
Provider Name (Legal Business Name): JACQUELIN VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 CRANE CREST WAY
ORLANDO FL
32825-4419
US

IV. Provider business mailing address

9919 CYPRESS KNEE CIR
ORLANDO FL
32825-9107
US

V. Phone/Fax

Practice location:
  • Phone: 407-241-9971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10098
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPACN96
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: