Provider Demographics
NPI:1134254618
Name:JACKSON, BEVERLY (ARNP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
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 1:2065 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3817
Mailing Address - Country:US
Mailing Address - Phone:904-387-4050
Mailing Address - Fax:904-387-4860
Practice Address - Street 1:2065 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3817
Practice Address - Country:US
Practice Address - Phone:904-387-4050
Practice Address - Fax:904-387-4860
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9240628363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD582YMedicare PIN