Provider Demographics
NPI:1629637566
Name:MCCOY, JESSIE LEE (C-AA)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LEE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:C-AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13708 MEADOWPARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-2636
Mailing Address - Country:US
Mailing Address - Phone:575-219-9802
Mailing Address - Fax:
Practice Address - Street 1:1775 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2620
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:866-478-8659
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAA523367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program