1639477789 NPI number — JACKSON HEALTH SYSTEM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639477789 NPI number — JACKSON HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HEALTH SYSTEM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639477789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2034 NW 145TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33028-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-585-1140
Provider Business Mailing Address Fax Number:
305-585-0031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16455 NE 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33162-3675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-955-6089
Provider Business Practice Location Address Fax Number:
786-955-6091
Provider Enumeration Date:
03/14/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEREIRA
Authorized Official First Name:
CLARE
Authorized Official Middle Name:
MAY
Authorized Official Title or Position:
FNP-BC, NP-C
Authorized Official Telephone Number:
954-632-9578

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  1896652 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)