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General NPI Number Information
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NPI Number | 1134759855
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Entity Type | Individual
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Provider Name | CHARLENE MARIE JACKSON RN
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Gender | Female
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Dates
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Enumeration Date | 01/22/2020
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Last Update Date | 01/22/2020
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Provider Practice Location Address
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Address Line | 1000 W BROADWAY ST STE 214
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City | OVIEDO
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State | FL
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Zip | 32765-9262
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Country | US
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Telephone | 407-359-5693
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Fax |
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Provider Business Mailing Address
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Address Line | 12564 HIDDEN GARDENS LN
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City | JACKSONVILLE
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State | FL
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Zip | 32258-3496
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Country | US
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Telephone | 904-262-6120
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Fax | 904-262-6120
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | RN9237888
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License Number State | FL
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