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General NPI Number Information
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NPI Number | 1205092186
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Entity Type | Organization
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Legal Business Name | JACKSON MEMORIAL HOSPITAL
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Dates
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Enumeration Date | 07/31/2008
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 1611 NW 12TH AVE ACC EAST ROOM 102
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City | MIAMI
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State | FL
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Zip | 33136-1005
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Country | US
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Telephone | 305-585-5241
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Fax | 305-585-5112
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Provider Business Mailing Address
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Address Line | 1611 NW 12TH AVE ACC EAST ROOM 102
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City | MIAMI
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State | FL
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Zip | 33136-1005
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Country | US
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Telephone | 305-585-5241
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Fax | 305-585-5112
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Authorized Official
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Title or Position | PAC WAIVER CASE MANAGER
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Name | MARIE -YOLAINE GASTON
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Credential | MASTER /MPH
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Telephone | 305-585-5241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282NC0060X
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Taxonomy Name | Critical Access Hospital
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License Number | G235559478070
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License Number State | FL
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