Provider Demographics
NPI:1790086841
Name:JACKSON, SARELYN BERTINA
Entity Type:Individual
Prefix:MS
First Name:SARELYN
Middle Name:BERTINA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CLAUDIA
Other - Middle Name:LOPEZ
Other - Last Name:BATZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARDMS
Mailing Address - Street 1:65 3RD ST NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4670
Mailing Address - Country:US
Mailing Address - Phone:863-299-2424
Mailing Address - Fax:863-299-4848
Practice Address - Street 1:65 3RD ST NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4670
Practice Address - Country:US
Practice Address - Phone:863-299-2424
Practice Address - Fax:863-299-4848
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL517812471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography