Healthcare Provider Details

I. General information

NPI: 1912539982
Provider Name (Legal Business Name): JESSICA CAROLYN PRICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1387 FRUIT COVE FOREST RD N
ST JOHNS FL
32259-2810
US

IV. Provider business mailing address

1387 FRUIT COVE FOREST RD N
ST JOHNS FL
32259-2810
US

V. Phone/Fax

Practice location:
  • Phone: 904-571-2300
  • Fax:
Mailing address:
  • Phone: 904-571-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: