Basic Information
| Provider Information | |||||||||
| NPI: | 1114572567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACON | ||||||||
| FirstName: | HANNAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100265 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650239 | ||||||||
| FaxNumber: | 3522651107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD STE 4102 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650239 | ||||||||
| FaxNumber: | 3522651107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2019 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9112430 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 104363800 | 05 | FL | MEDICAID |