Provider Demographics
NPI:1134699481
Name:JACKSON, ANITA DIONNE
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:DIONNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:DIONNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17 OLD KINGS RD N STE E
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8283
Mailing Address - Country:US
Mailing Address - Phone:386-264-1398
Mailing Address - Fax:386-303-5536
Practice Address - Street 1:29 BALTIMORE LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8851
Practice Address - Country:US
Practice Address - Phone:386-264-1398
Practice Address - Fax:386-303-5536
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
FL30212414251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid