Provider Demographics
NPI:1235786377
Name:JACKSON, ALICIA NYKIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:NYKIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4293
Mailing Address - Country:US
Mailing Address - Phone:954-394-8518
Mailing Address - Fax:
Practice Address - Street 1:3060 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-4293
Practice Address - Country:US
Practice Address - Phone:954-394-8518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9288975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily