Provider Demographics
NPI:1184931974
Name:PACKWOOD, JESSICA SUSAN (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSAN
Last Name:PACKWOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUSAN
Other - Last Name:SLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1720 S ORANGE AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2945
Mailing Address - Country:US
Mailing Address - Phone:407-426-9693
Mailing Address - Fax:407-426-9694
Practice Address - Street 1:1720 S ORANGE AVE
Practice Address - Street 2:STE 500
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2945
Practice Address - Country:US
Practice Address - Phone:407-426-9693
Practice Address - Fax:407-426-9694
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104743363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical