Provider Demographics
NPI:1114678257
Name:JACKSON, TENA MARIA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TENA
Middle Name:MARIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 SE VOLKERTS TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3873
Mailing Address - Country:US
Mailing Address - Phone:740-794-1919
Mailing Address - Fax:
Practice Address - Street 1:1300 ST LUCIE W BLVD
Practice Address - Street 2:CLINIC #5157
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2109
Practice Address - Country:US
Practice Address - Phone:772-878-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2021117108363L00000X
FL11017532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner