Provider Demographics
NPI:1063495281
Name:RICKETTS, JEFFREY D (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 KING ST
Mailing Address - Street 2:STE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-384-3343
Mailing Address - Fax:904-400-6671
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:STE 1804
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-398-3888
Practice Address - Fax:904-400-6675
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103298363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292285100Medicaid
FLU5605VMedicare PIN
FLQ50909Medicare UPIN