Provider Demographics
NPI:1225797566
Name:JACKSON, BEULAH (PHLEBOTOMIST)
Entity Type:Individual
Prefix:
First Name:BEULAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
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 1362
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-1362
Mailing Address - Country:US
Mailing Address - Phone:352-292-6433
Mailing Address - Fax:
Practice Address - Street 1:603 PETERS ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3927
Practice Address - Country:US
Practice Address - Phone:352-292-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty