Healthcare Provider Details

I. General information

NPI: 1093899288
Provider Name (Legal Business Name): JACKSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1990 SW 33RD CT
MIAMI FL
33145-2226
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-6199
  • Fax:
Mailing address:
  • Phone: 305-301-7179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License NumberARNP2618882
License Number StateFL

VIII. Authorized Official

Name: JACQUELINE FERRER
Title or Position: RENAL MANAGEMENT ARNP
Credential: ARNP
Phone: 305-585-6199