Provider Demographics
NPI:1720024698
Name:DEROCHER, JAYNE ELLEN (APRN)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:ELLEN
Last Name:DEROCHER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 CENTURY MEDICAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6264
Mailing Address - Fax:321-268-6273
Practice Address - Street 1:494 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2871
Practice Address - Country:US
Practice Address - Phone:321-267-8311
Practice Address - Fax:321-267-2881
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN2836232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306630400Medicaid
FLP00281210OtherRAILROAD
FLY090COtherBCBS
Q32050Medicare UPIN
FLU4042ZMedicare ID - Type Unspecified