Provider Demographics
NPI:1346748688
Name:JACKSON, CARMEN RENEE (ARNP, FNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:CARMEN
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 EUCLID AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-6526
Mailing Address - Country:US
Mailing Address - Phone:305-726-4727
Mailing Address - Fax:
Practice Address - Street 1:1005 N LAKE PARKER AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4723
Practice Address - Country:US
Practice Address - Phone:863-583-4053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP935595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily