Provider Demographics
NPI:1598060550
Name:FERGUSON, JEAN TAYLOR (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:TAYLOR
Last Name:FERGUSON
Suffix:
Gender:F
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 1:8075 GATE PARKWAY W
Mailing Address - Street 2:#305
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-296-2992
Mailing Address - Fax:904-296-2993
Practice Address - Street 1:8075 GATE PARKWAY W
Practice Address - Street 2:#305
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-296-2992
Practice Address - Fax:904-296-2993
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106099363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4598800Medicaid