=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811376601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LYNN DOUGLAS FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 SW STONEGATE TER STE 103
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32024-3457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-1655
-----------------------------------------------------
Fax | 386-628-9231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 WOODMONT BLVD STE 500
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37205-2245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-475-4151
-----------------------------------------------------
Fax | 559-421-7004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 9310684
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN9310684
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------