Healthcare Provider Details

I. General information

NPI: 1649187279
Provider Name (Legal Business Name): TINA JACKSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 KESTREL CT
ROCKLEDGE FL
32955-6350
US

IV. Provider business mailing address

1618 KESTREL CT
ROCKLEDGE FL
32955-6350
US

V. Phone/Fax

Practice location:
  • Phone: 321-470-2707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: