Provider Demographics
NPI:1609464130
Name:JACKSON, MARSHA (APRN)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 NW 57TH WAY
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2420
Mailing Address - Country:US
Mailing Address - Phone:954-471-9220
Mailing Address - Fax:
Practice Address - Street 1:5600 NW 57TH WAY
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2420
Practice Address - Country:US
Practice Address - Phone:954-471-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
FL9236954363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty