Provider Demographics
NPI:1972277317
Name:JACKSON, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
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 1:24267 SW 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-4404
Mailing Address - Country:US
Mailing Address - Phone:305-951-8358
Mailing Address - Fax:
Practice Address - Street 1:24267 SW 117TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-4404
Practice Address - Country:US
Practice Address - Phone:305-951-8358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9300641163WG0000X
FL9303641163WG0600X, 163WI0600X, 163WW0000X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Single Specialty
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WW0000XNursing Service ProvidersRegistered NurseWound Care