Basic Information
| Provider Information | |||||||||
| NPI: | 1295178580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASSITER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 550 REDSTONE AVE W STE 470 | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325366457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506892229 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 REDSTONE AVE W STE 470 | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325366457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506892229 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 24652 | MS | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | MD.34009 | AL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | ME140756 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.