MEDICARE: GRACIE LATRICE JENKINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN11045076	FL
2	207Q00000X	Family Medicine Physician	APRN11045076	FL

General Provider Information

NPI Number	:	1023967973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACIE LATRICE JENKINS

Provider Business Mailing Address
First Line	:	3605 LIGHT PORT WAY
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-1842
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3605 LIGHT PORT WAY
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-1842
Country	:	US
Telephone Number	:	689-239-9633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2026
Last Update Date	:	05/22/2026

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Directions to “ GRACIE LATRICE JENKINS ” Practice Location

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