Provider Demographics
NPI:1942655592
Name:ANDERSON, JESSICA DAWN (ARNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DAWN
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4315 HIGHLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1639
Mailing Address - Country:US
Mailing Address - Phone:863-255-4777
Mailing Address - Fax:863-940-4856
Practice Address - Street 1:4315 HIGHLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1639
Practice Address - Country:US
Practice Address - Phone:863-255-4777
Practice Address - Fax:863-940-4856
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9213300363LG0600X
FLAPRN9213300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIU868ZOtherMEDICAID
FL017604000Medicaid