Provider Demographics
NPI:1891753166
Name:JACKSON, MARTIE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARTIE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 S PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6007
Mailing Address - Country:US
Mailing Address - Phone:813-653-3359
Mailing Address - Fax:813-662-9639
Practice Address - Street 1:876 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6007
Practice Address - Country:US
Practice Address - Phone:813-653-3359
Practice Address - Fax:813-662-9639
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3050652363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7474WMedicare PIN