Provider Demographics
NPI:1376092809
Name:FACUNDUS, JACK (ARNP)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:FACUNDUS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 BERKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5403
Mailing Address - Country:US
Mailing Address - Phone:407-760-9605
Mailing Address - Fax:
Practice Address - Street 1:651 W WARREN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4036
Practice Address - Country:US
Practice Address - Phone:321-999-9617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2824142363LF0000X
NH090740-23363LF0000X
FLAPRN2824142363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP2824142OtherSTATE OF FLORIDA ARNP LICENSE
FLF0416038OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION PROGRAM
FLF0416038OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION PROGRAM