Basic Information
| Provider Information | |||||||||
| NPI: | 1679092050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | JESSICA | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | ATTN: MANAGED CARE DEPT. | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 PABLO ST | ||||||||
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| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632845020 | ||||||||
| FaxNumber: | 8632845912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2017 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9293649 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207RC0000X | 9293649 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.