Provider Demographics
NPI:1063018133
Name:CONDE, JACKELINE (APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACKELINE
Middle Name:
Last Name:CONDE
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 SW IMPORT DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2051
Mailing Address - Country:US
Mailing Address - Phone:305-216-1619
Mailing Address - Fax:
Practice Address - Street 1:808 SW GLENVIEW CT, SUITES 812 AND 814
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3495
Practice Address - Country:US
Practice Address - Phone:772-240-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily