Provider Demographics
NPI:1477568178
Name:JACKSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JACKSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MS
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUZOD
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, MSN
Authorized Official - Phone:786-263-4935
Mailing Address - Street 1:405 NW 130TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-3746
Mailing Address - Country:US
Mailing Address - Phone:305-685-7277
Mailing Address - Fax:
Practice Address - Street 1:13850 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-3004
Practice Address - Country:US
Practice Address - Phone:786-263-4935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1245132261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center