Healthcare Provider Details

I. General information

NPI: 1932742590
Provider Name (Legal Business Name): RIITTA HELENA KUKKASTENVEHMAS-JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 N MAGNOLIA AVE
ORLANDO FL
32803-3809
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 74-237-1494
  • Fax:
Mailing address:
  • Phone: 864-797-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number23345
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: