Provider Demographics
NPI:1891016705
Name:ORCINO, JACQUELYN HODES (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:HODES
Last Name:ORCINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:180 N WATERSOUND PKWY
Practice Address - Street 2:
Practice Address - City:INLET BEACH
Practice Address - State:FL
Practice Address - Zip Code:32461-7274
Practice Address - Country:US
Practice Address - Phone:850-278-3551
Practice Address - Fax:850-278-3596
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2113020Medicaid
LA5CQ60PD41Medicare PIN
FLAG883Medicare PIN