Provider Demographics
NPI:1639607732
Name:HATTEN, JACKIE DALE JR (ARNP)
Entity Type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:DALE
Last Name:HATTEN
Suffix:JR
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N WEST SHORE BLVD STE 635
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1910
Mailing Address - Country:US
Mailing Address - Phone:813-513-9493
Mailing Address - Fax:904-562-3317
Practice Address - Street 1:500 N WEST SHORE BLVD STE 635
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1910
Practice Address - Country:US
Practice Address - Phone:813-513-9493
Practice Address - Fax:904-562-3317
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3419772363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639607732OtherEMPLOYER DOSE NOT TAKE INSURANCE