Provider Demographics
NPI:1093869794
Name:JACKSON MEM HOS
Entity Type:Organization
Organization Name:JACKSON MEM HOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:VIVIENNE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-585-6677
Mailing Address - Street 1:10429 OAK MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-5470
Mailing Address - Country:US
Mailing Address - Phone:561-968-5169
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital