Healthcare Provider Details

I. General information

NPI: 1457625568
Provider Name (Legal Business Name): JEANETTE MORTARA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CREIGHTON RD
PENSACOLA FL
32504-7028
US

IV. Provider business mailing address

219 CLEAR LAKE DR
PENSACOLA FL
32507-8126
US

V. Phone/Fax

Practice location:
  • Phone: 850-564-6644
  • Fax: 866-740-0655
Mailing address:
  • Phone: 251-978-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906790
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3-002281
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN 1952492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: