Provider Demographics
NPI:1740567460
Name:SANDERSON, JENNIFER (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9332786367500000X
FLAPRN9332786207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004297100Medicaid
FLFP347XMedicare PIN
FL0042971-00Medicaid