Provider Demographics
NPI:1093959348
Name:JETT, WESLEY W (PA-C)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:W
Last Name:JETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SAN MARCO BLVD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8568
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-396-0388
Practice Address - Street 1:1325 SAN MARCO BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8568
Practice Address - Country:US
Practice Address - Phone:904-346-3465
Practice Address - Fax:904-396-0388
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104984363AM0700X, 363AS0400X
FLPA9104984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003777500Medicaid
FLBV574YMedicare PIN