Provider Demographics
NPI:1114563301
Name:WOODALL, JESSICA CORNELIA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CORNELIA
Last Name:WOODALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 COVINGTON CREEK CIR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1181
Mailing Address - Country:US
Mailing Address - Phone:954-303-0419
Mailing Address - Fax:
Practice Address - Street 1:4866 BIG ISLAND DR UNIT 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-5301
Practice Address - Country:US
Practice Address - Phone:904-652-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015255363LF0000X
FL9435365163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatrics