Provider Demographics
NPI:1528566353
Name:LAND, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 SW CHOCTAW AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:653 SW CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038
Practice Address - Country:US
Practice Address - Phone:386-623-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175F00000XOther Service ProvidersNaturopath
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022880200Medicaid