Healthcare Provider Details

I. General information

NPI: 1497614986
Provider Name (Legal Business Name): JACKSONVILLE AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2026
Last Update Date: 01/20/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BARREN WAY
ST. JOHNS FL
32259
US

IV. Provider business mailing address

75 BARREN WAY
ST. JOHNS FL
32259
US

V. Phone/Fax

Practice location:
  • Phone: 904-889-0061
  • Fax:
Mailing address:
  • Phone: 904-889-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE THIBODEAUX
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 904-889-0061