Provider Demographics
NPI:1033988514
Name:JACKSON, SISELY ROSE (RN, CNE)
Entity Type:Individual
Prefix:MS
First Name:SISELY
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, CNE
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 6298
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32314-6298
Mailing Address - Country:US
Mailing Address - Phone:732-895-3700
Mailing Address - Fax:
Practice Address - Street 1:425 SE 1ST ST APT 811
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-7567
Practice Address - Country:US
Practice Address - Phone:732-895-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9236361163WX0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk