Provider Demographics
NPI:1326787334
Name:JACKSON, JAYLEENE
Entity Type:Individual
Prefix:
First Name:JAYLEENE
Middle Name:
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 1:4140 GAUGE LINE LOOP
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5130
Mailing Address - Country:US
Mailing Address - Phone:484-219-7873
Mailing Address - Fax:
Practice Address - Street 1:4140 GAUGE LINE LOOP
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-5130
Practice Address - Country:US
Practice Address - Phone:484-219-7873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30878571222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist