Healthcare Provider Details

I. General information

NPI: 1396776571
Provider Name (Legal Business Name): MARY R JACOB ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ORLANDO AVE
WINTER PARK FL
32789-5547
US

IV. Provider business mailing address

1600 S ORLANDO AVE
WINTER PARK FL
32789-5547
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-4692
  • Fax:
Mailing address:
  • Phone: 407-644-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberARNP 1859582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: