=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023621596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON JOHN BAILEY APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2853 HENLEY RD STE 103
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-8616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-602-4510
-----------------------------------------------------
Fax | 904-602-4519
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2853 HENLEY RD STE 103
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-8616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 46-024-5109
-----------------------------------------------------
Fax | 904-602-4519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11007519
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------