Provider Demographics
NPI:1952875296
Name:HENRY, JACQUELINE FRISCIA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:FRISCIA
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:FRISCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2118 W ERNA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2720
Mailing Address - Country:US
Mailing Address - Phone:813-317-7403
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-553-7300
Practice Address - Fax:727-553-7395
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLREQQTOtherBCBS
FL102105900Medicaid