Healthcare Provider Details

I. General information

NPI: 1609527183
Provider Name (Legal Business Name): JESSICA CLINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 SUNSHINE DR
WILDWOOD FL
34785-7754
US

IV. Provider business mailing address

5190 SUNSHINE DR
WILDWOOD FL
34785-7754
US

V. Phone/Fax

Practice location:
  • Phone: 270-300-0955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: