Healthcare Provider Details

I. General information

NPI: 1043822257
Provider Name (Legal Business Name): JENNA R HURLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 DOCTORS DR
PANAMA CITY FL
32405-4517
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 850-785-8557
  • Fax:
Mailing address:
  • Phone: 352-205-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: