Provider Demographics
NPI:1912032558
Name:NUNEZ, JACKELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:
Last Name:NUNEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 CORPORATE CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7760
Mailing Address - Country:US
Mailing Address - Phone:702-910-3950
Mailing Address - Fax:
Practice Address - Street 1:5425 PARK ST N STE 7W
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-7042
Practice Address - Country:US
Practice Address - Phone:727-202-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN487207Q00000X, 207R00000X, 207VG0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN487OtherFL MEDICAL LICENSE
FL010963800Medicaid