Healthcare Provider Details

I. General information

NPI: 1598862880
Provider Name (Legal Business Name): JACKSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
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

2705 SW 129TH AVE
MIRAMAR FL
33027-3849
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5116
  • Fax:
Mailing address:
  • Phone: 954-447-9659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NW0100X
TaxonomyWomen's Hospital
License Number2213562
License Number StateFL

VIII. Authorized Official

Name: MRS. JOY ADELLA GLAZE
Title or Position: ARNP
Credential: ARNP
Phone: 305-585-5116