Healthcare Provider Details

I. General information

NPI: 1578487856
Provider Name (Legal Business Name): KIERA JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CENTERVILLE RD STE 300
TALLAHASSEE FL
32308-4675
US

IV. Provider business mailing address

1401 CENTERVILLE RD STE 300
TALLAHASSEE FL
32308-4639
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-5115
  • Fax:
Mailing address:
  • Phone: 850-877-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11039051
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: