Provider Demographics
NPI:1851743504
Name:VINCENT, JACQUELIN
Entity type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9919 CYPRESS KNEE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-9107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1307 CRANE CREST WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4419
Practice Address - Country:US
Practice Address - Phone:407-241-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10098363AM0700X
FLPACN96363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10098Medicaid
FL246ZC0007XOtherFIRST SURGICAL ASSISTANT
FLPACN96Medicaid