Provider Demographics
NPI:1851391510
Name:JASKULSKY, LOIS (ARNP)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:JASKULSKY
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 1:3635 S CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-2300
Mailing Address - Country:US
Mailing Address - Phone:386-788-1242
Mailing Address - Fax:386-788-4255
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-788-1242
Practice Address - Fax:386-788-4255
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP711642363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0985ZMedicare PIN
FL99019Medicare ID - Type Unspecified