Provider Demographics
NPI:1639588031
Name:BELLIAMINOWA JACKSON
Entity Type:Organization
Organization Name:BELLIAMINOWA JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BELLIAMINOWA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-484-0088
Mailing Address - Street 1:17761 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3924
Mailing Address - Country:US
Mailing Address - Phone:786-484-0088
Mailing Address - Fax:786-484-0190
Practice Address - Street 1:17761 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3924
Practice Address - Country:US
Practice Address - Phone:786-484-0088
Practice Address - Fax:786-484-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278195600Medicaid