Provider Demographics
NPI:1841275864
Name:JAIN, AUDREY ELAINE (DO)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:ELAINE
Last Name:JAIN
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:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-5004
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1033 N PARKWAY FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-0401
Practice Address - Country:US
Practice Address - Phone:863-647-8011
Practice Address - Fax:863-647-8021
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS125242084P0800X
GA822592084P0800X
ARE-118992084P0800X
NJ25MB104927002084P0800X
TN36332084P0800X
DCDO0348002084P0800X
DEC200129752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry