Provider Demographics
NPI:1922692516
Name:JACKSON, CHAUNYALE TIFFANY (RN)
Entity Type:Individual
Prefix:
First Name:CHAUNYALE
Middle Name:TIFFANY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5260
Mailing Address - Country:US
Mailing Address - Phone:402-891-1118
Mailing Address - Fax:
Practice Address - Street 1:14550 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2460
Practice Address - Country:US
Practice Address - Phone:904-271-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9557857163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse