Basic Information
Provider Information | |||||||||
NPI: | 1962565192 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOOD | ||||||||
FirstName: | JERRI | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN,BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2323 S ORANGE AVE | ||||||||
Address2: | STE A | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328063059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047576999 | ||||||||
FaxNumber: | 3042015019 | ||||||||
Practice Location | |||||||||
Address1: | 301 GREAT TEAYS BLVD STE 6 | ||||||||
Address2: |   | ||||||||
City: | SCOTT DEPOT | ||||||||
State: | WV | ||||||||
PostalCode: | 255609552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047576999 | ||||||||
FaxNumber: | 3042015019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 09/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9352901 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3810013710 | 05 | WV |   | MEDICAID | 5630092000 | 05 | WV |   | MEDICAID | 3810011888 | 05 | WV |   | MEDICAID |