Healthcare Provider Details

I. General information

NPI: 1881189140
Provider Name (Legal Business Name): JACOB EDWARD SHELLEY ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE STE 305
PENSACOLA FL
32504-5719
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-6159
  • Fax:
Mailing address:
  • Phone: 904-450-6014
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9375373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: