Provider Demographics
NPI:1619204955
Name:ROCKSWOLD, JESSICA MICHELE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELE
Last Name:ROCKSWOLD
Suffix:
Gender:F
Credentials:PA
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 606
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-0606
Mailing Address - Country:US
Mailing Address - Phone:904-653-1818
Mailing Address - Fax:904-653-1814
Practice Address - Street 1:1419 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-4624
Practice Address - Country:US
Practice Address - Phone:904-653-1822
Practice Address - Fax:904-259-1225
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001673300Medicaid