Provider Demographics
NPI:1710966346
Name:SHOTWELL, JESSICA (ARNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHOTWELL
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 1:4196 W US HIGHWAY 90 STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8834
Mailing Address - Country:US
Mailing Address - Phone:386-243-8474
Mailing Address - Fax:386-438-5945
Practice Address - Street 1:4196 W US HIGHWAY 90 STE 105
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8834
Practice Address - Country:US
Practice Address - Phone:386-243-8474
Practice Address - Fax:386-438-5945
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9220069363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307391200Medicaid