Provider Demographics
NPI:1780143628
Name:MEDINA, JACQUELYN (DO)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5148
Mailing Address - Country:US
Mailing Address - Phone:904-639-2000
Mailing Address - Fax:904-639-2015
Practice Address - Street 1:1361 13TH AVE S STE 180
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3235
Practice Address - Country:US
Practice Address - Phone:904-247-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS19989207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program