Provider Demographics
NPI:1619305174
Name:JACKSON, ROSEMARY (MD, MPH)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 APPALOOSA TRL
Mailing Address - Street 2:
Mailing Address - City:BAHAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27503-9621
Mailing Address - Country:US
Mailing Address - Phone:954-649-5029
Mailing Address - Fax:919-768-9193
Practice Address - Street 1:4960 SW 72ND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5544
Practice Address - Country:US
Practice Address - Phone:954-649-5029
Practice Address - Fax:919-768-9193
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35379207Q00000X
NY263617207Q00000X
VA0101047114207Q00000X
FLME92761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine