Provider Demographics
NPI:1669144317
Name:JACKSON, RUTH
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
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 1:225 SWAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463
Mailing Address - Country:US
Mailing Address - Phone:561-635-5130
Mailing Address - Fax:
Practice Address - Street 1:225 SWAIN BLVD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463
Practice Address - Country:US
Practice Address - Phone:561-635-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL091972171W00000X
FL081972171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL091972OtherAPD