Provider Demographics
NPI:1700829033
Name:CRISOSTOMO, JODY VICENCIO (PAC)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:VICENCIO
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:PAC
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 57970
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-7970
Mailing Address - Country:US
Mailing Address - Phone:904-737-1838
Mailing Address - Fax:
Practice Address - Street 1:4243 SUNBEAM RD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8975
Practice Address - Country:US
Practice Address - Phone:904-737-1838
Practice Address - Fax:904-737-1206
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S65611Medicare UPIN
FLE1399YMedicare ID - Type Unspecified