Provider Demographics
NPI:1609229343
Name:TANNER, JACKIE R (ARNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:TANNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 HARRISON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2662
Mailing Address - Country:US
Mailing Address - Phone:850-558-4400
Mailing Address - Fax:
Practice Address - Street 1:638 HARRISON AVE STE 102
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2662
Practice Address - Country:US
Practice Address - Phone:850-558-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9208911363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIR613ZMedicare PIN