Provider Demographics
NPI:1780664854
Name:JACKSON, MARY KATHERINE (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2521 SUNNY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4970
Mailing Address - Country:US
Mailing Address - Phone:904-542-7516
Mailing Address - Fax:904-542-7913
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-7516
Practice Address - Fax:904-542-7913
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA420469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily