MEDICARE: DR. JESSICA PROCTOR PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PS55572	FL

General Provider Information

NPI Number	:	1265035737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA PROCTOR PHARMD

Provider Business Mailing Address
First Line	:	1812 OCEAN DR S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6243
Country	:	US
Telephone Number	:	850-502-0984
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 MARSH LANDING PKWY
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-5855
Country	:	US
Telephone Number	:	904-273-6387
Fax Number	:

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

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	11/18/2020

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