Provider Demographics
NPI:1922256437
Name:POLK, JACKIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3904
Mailing Address - Country:US
Mailing Address - Phone:863-297-1702
Mailing Address - Fax:863-291-6755
Practice Address - Street 1:1201 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3904
Practice Address - Country:US
Practice Address - Phone:863-297-1702
Practice Address - Fax:863-291-6755
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN340111164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse