Provider Demographics
NPI:1639179435
Name:JACKSON, JOHNNA L (ARNP)
Entity type:Individual
Prefix:MRS
First Name:JOHNNA
Middle Name:L
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 1:1847 SW BARNETT WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025
Mailing Address - Country:US
Mailing Address - Phone:386-755-2240
Mailing Address - Fax:386-755-6598
Practice Address - Street 1:1847 SW BARNETT WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-755-2240
Practice Address - Fax:386-755-6598
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2552432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301881400Medicaid