Provider Demographics
NPI:1740098946
Name:SCALES, JETIA LASONJA (AGNP-C)
Entity type:Individual
Prefix:
First Name:JETIA
Middle Name:LASONJA
Last Name:SCALES
Suffix:
Gender:
Credentials:AGNP-C
Other - Prefix:
Other - First Name:JATIA
Other - Middle Name:LASONJA
Other - Last Name:SCALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGNP-C
Mailing Address - Street 1:8613 OLD KINGS RD S STE 602
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4863
Mailing Address - Country:US
Mailing Address - Phone:904-504-5225
Mailing Address - Fax:
Practice Address - Street 1:8613 OLD KINGS RD S STE 602
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4863
Practice Address - Country:US
Practice Address - Phone:904-504-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036888363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner