Provider Demographics
NPI:1588624761
Name:JACQMEIN, JEFFRY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:ALAN
Last Name:JACQMEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:8789 SAN JOSE BLVD STE 111
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4253
Practice Address - Country:US
Practice Address - Phone:904-376-3500
Practice Address - Fax:904-390-7519
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 71303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG64835Medicare UPIN
FL42537AMedicare ID - Type Unspecified