Provider Demographics
NPI:1114572567
Name:JACON, HANNAH (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:JACON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100265
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0265
Mailing Address - Country:US
Mailing Address - Phone:352-265-0239
Mailing Address - Fax:352-265-1107
Practice Address - Street 1:1600 SW ARCHER RD STE 4102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0239
Practice Address - Fax:352-265-1107
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104363800Medicaid