Provider Demographics
NPI:1619748019
Name:JACKSON, JENICE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:JENICE
Middle Name:ANTOINETTE
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 1:706 BOND ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-3012
Mailing Address - Country:US
Mailing Address - Phone:863-244-9112
Mailing Address - Fax:
Practice Address - Street 1:706 BOND ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-3012
Practice Address - Country:US
Practice Address - Phone:863-244-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9637641163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse