Provider Demographics
NPI:1568809937
Name:JACKSON, CHAQUERA ERNESTA
Entity Type:Individual
Prefix:MS
First Name:CHAQUERA
Middle Name:ERNESTA
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:PO BOX 2900
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-2900
Mailing Address - Country:US
Mailing Address - Phone:772-288-2400
Mailing Address - Fax:772-419-0143
Practice Address - Street 1:1050 SE MONTEREY RD STE 400
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-288-2400
Practice Address - Fax:772-419-0143
Is Sole Proprietor?:No
Enumeration Date:2013-05-26
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FL9111232363AM0700X
FLPA9111232363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical