Healthcare Provider Details

I. General information

NPI: 1053927962
Provider Name (Legal Business Name): JACKELINE ANDREA MARX CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W SUNRISE BLVD
PLANTATION FL
33322-4113
US

IV. Provider business mailing address

3654 NW 85TH TER
PEMBROKE PINES FL
33024-5100
US

V. Phone/Fax

Practice location:
  • Phone: 800-437-2672
  • Fax:
Mailing address:
  • Phone: 305-316-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number615
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: