Provider Demographics
NPI:1245894187
Name:JACKSON, ANNESIA KATRINA (RN)
Entity type:Individual
Prefix:
First Name:ANNESIA
Middle Name:KATRINA
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 1:1950 LEE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1847
Mailing Address - Country:US
Mailing Address - Phone:407-956-1870
Mailing Address - Fax:407-641-8178
Practice Address - Street 1:1950 LEE RD STE 104
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1847
Practice Address - Country:US
Practice Address - Phone:407-956-1870
Practice Address - Fax:407-641-8178
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9500989163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9500989OtherFLORIDA NURSING LICENSE