Provider Demographics
NPI:1770218513
Name:JACKSON, ALEXANDRA JABORNIK
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JABORNIK
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 1:7807 BAYMEADOWS RD E STE 207
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9666
Mailing Address - Country:US
Mailing Address - Phone:904-446-9991
Mailing Address - Fax:904-446-9992
Practice Address - Street 1:12311 WATERFALL CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6801
Practice Address - Country:US
Practice Address - Phone:239-877-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAPRN11027845364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program