Healthcare Provider Details

I. General information

NPI: 1679943245
Provider Name (Legal Business Name): FANNY JACKSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 10TH AVE N SUITE 1000
PALM SPRINGS FL
33461-3141
US

IV. Provider business mailing address

38754 STATE ROAD 80
BELLE GLADE FL
33430-5615
US

V. Phone/Fax

Practice location:
  • Phone: 561-642-1008
  • Fax: 561-802-3976
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH23160
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: