Healthcare Provider Details

I. General information

NPI: 1720756265
Provider Name (Legal Business Name): MARIAH JACKSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0406
  • Fax: 407-975-0407
Mailing address:
  • Phone: 727-846-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPRN11016395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: