Provider Demographics
NPI:1326788563
Name:JACKSON, TAIWAN (LPN)
Entity Type:Individual
Prefix:
First Name:TAIWAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 S OAK AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-4100
Mailing Address - Country:US
Mailing Address - Phone:407-864-5534
Mailing Address - Fax:
Practice Address - Street 1:2510 S OAK AVE STE C
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-4100
Practice Address - Country:US
Practice Address - Phone:407-864-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5241013164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse