Provider Demographics
NPI:1861030835
Name:JACKSON, AVIS SHANTRELL
Entity Type:Individual
Prefix:
First Name:AVIS
Middle Name:SHANTRELL
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 1:1700 NW 66TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-7444
Mailing Address - Country:US
Mailing Address - Phone:786-333-4557
Mailing Address - Fax:
Practice Address - Street 1:1700 NW 66TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-7444
Practice Address - Country:US
Practice Address - Phone:786-333-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty