Provider Demographics
NPI:1912032558
Name:NUNEZ, JACKELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:
Last Name:NUNEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:970 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1766
Practice Address - Country:US
Practice Address - Phone:772-249-1501
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN487207R00000X, 207VG0400X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010963800Medicaid
FLH30380Medicare UPIN