Healthcare Provider Details

I. General information

NPI: 1104603364
Provider Name (Legal Business Name): JENNIFER MELISSA JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER DURAN

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SW FOUNTAINVIEW BLVD STE 105
PORT SAINT LUCIE FL
34986-4527
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 772-336-2818
  • Fax: 772-336-5313
Mailing address:
  • Phone: 772-336-2818
  • Fax: 772-336-5313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11028311
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: