Provider Demographics
NPI:1780658617
Name:HENRY, JANE ELLEN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ELLEN
Last Name:HENRY
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 1:580 STATE ROAD 206 WEST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:954-695-3643
Mailing Address - Fax:954-695-3643
Practice Address - Street 1:580 STATE ROAD 206 WEST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:954-695-3643
Practice Address - Fax:954-695-3643
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3000182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC299OtherMEDICARE GROUP NUMBER
FLP00381167OtherRR MEDICARE
FLP00381167OtherRR MEDICARE
FLAC299OtherMEDICARE GROUP NUMBER
FLQ68811Medicare UPIN