Healthcare Provider Details

I. General information

NPI: 1780664854
Provider Name (Legal Business Name): MARY KATHERINE JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

2521 SUNNY CREEK DR
ORANGE PARK FL
32003-4970
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7516
  • Fax: 904-542-7913
Mailing address:
  • Phone: 904-542-7516
  • Fax: 904-542-7913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number420469
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: