Healthcare Provider Details

I. General information

NPI: 1245894187
Provider Name (Legal Business Name): ANNESIA KATRINA JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 LEE RD STE 104
WINTER PARK FL
32789-1847
US

IV. Provider business mailing address

1950 LEE RD STE 104
WINTER PARK FL
32789-1847
US

V. Phone/Fax

Practice location:
  • Phone: 407-956-1870
  • Fax: 407-641-8178
Mailing address:
  • Phone: 407-956-1870
  • Fax: 407-641-8178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9500989
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: