Provider Demographics
NPI:1588974869
Name:ARCHIE, JESICA CLEVELAND (MSN)
Entity type:Individual
Prefix:
First Name:JESICA
Middle Name:CLEVELAND
Last Name:ARCHIE
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2945
Mailing Address - Country:US
Mailing Address - Phone:407-540-1000
Mailing Address - Fax:407-540-1011
Practice Address - Street 1:1720 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2945
Practice Address - Country:US
Practice Address - Phone:407-540-1000
Practice Address - Fax:407-540-1011
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4317363LP0200X
FLAPRN9497670363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105761900Medicaid
SC4317OtherAPRN LICENSE NUMBER