Basic Information
Provider Information | |||||||||
NPI: | 1588110605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GLEASON | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: | PATRICIA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4930 E LAKE MARY BLVD | ||||||||
Address2: |   | ||||||||
City: | SANFORD | ||||||||
State: | FL | ||||||||
PostalCode: | 327715003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073228645 | ||||||||
FaxNumber: | 4072698986 | ||||||||
Practice Location | |||||||||
Address1: | 5730 LAKE UNDERHILL RD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328074366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079271765 | ||||||||
FaxNumber: | 4072698986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2016 | ||||||||
LastUpdateDate: | 08/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN9233301 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | APRN9233301 | 01 | FL | STATE LICENSE | OTHER |