Healthcare Provider Details

I. General information

NPI: 1528160181
Provider Name (Legal Business Name): TERESA A JACKSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20612 NW 27TH AVE
MIAMI GARDENS FL
33056-1469
US

IV. Provider business mailing address

5607 NW 27TH AVE STE 1
MIAMI FL
33142-2826
US

V. Phone/Fax

Practice location:
  • Phone: 305-637-6400
  • Fax: 305-636-5155
Mailing address:
  • Phone: 305-805-1700
  • Fax: 305-805-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2904542
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2904542
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: