License Verification

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JENNIFER KRISTIN KOELLER

License Number: PA9108194

Data As Of 10/25/2025

Profession
Physician Assistant
License
PA9108194
License Status
Clear/Active
Qualifications
Prescribing
License Expiration Date
1/31/2026
License Original Issue Date
09/09/2014
Address of Record
8575 NE 138TH LANE SUITE 203
LADY LAKE, FL 32159
Controlled Substance Prescriber (for the Treatment of Chronic Non-malignant Pain)
No
Discipline on File
No
Public Complaint
No
Address
8575 NE. 138TH LN. SUITE 203 VILLAGE HEART & VEIN CENTER
LADY LAKE, FL 32159
Address
1451 El Camino Real
THE VILLAGES, FL 32159
Address
600 E. Dixie Ave
LEESBURG, FL 34748
Address
1451 El Camino Real The Villages Regional Hospital
THE VILLAGES, FL 32159
Address
1500 SW 1st Ave Munroe Regional Medical Center
OCALA, FL 34471
Address
1350 Hickory St Holmes Regional Medical Center
MELBOURNE, FL 32901
Address
2010 59th St W Black Medical Center
BRADENTON, FL 34209
Address
502 W. Highland Blvd Citrus Memorial Hospital
INVERNESS, FL 34452
Address
1000 Waterman Way
TAVARES, FL 32778
Name Relationship Profession License Effective Date
ANTAKI, TAMIM Supervising Prescribing Practitioner Medical Doctor 128056 09/12/2025
CAMPBELL, MATTHEW Supervising Prescribing Practitioner Medical Doctor 98326 09/12/2025

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Name Relationship Profession License Effective Date

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Name Relationship Profession License Effective Date

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No Continuing Education Hours Received from Approved Providers As Of 10/25/2025



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** Personal Development is limited to no more than 3 hours per renewal cycle. Any personal development hours in excess of this 3 hour maximum cannot be used for renewal and have been subtracted from the total available for renewal.


Please do not fax proof of Continuing Education hours to the Board Office until you have received your renewal notice in the mail.


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