Basic Information
| Provider Information | |||||||||
| NPI: | 1417040155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 22ND AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337052933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273100925 | ||||||||
| FaxNumber: | 7274985470 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 22ND AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337052933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273100925 | ||||||||
| FaxNumber: | 7274985470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME159307 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2451305 | 05 | OH | MEDICAID |