MEDICARE: DEANA GISELLE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	9235518	FL

General Provider Information

NPI Number	:	1316707425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANA GISELLE JACKSON

Provider Business Mailing Address
First Line	:	3518 CYPRESS TRL APT D208
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-3313
Country	:	US
Telephone Number	:	561-452-8262
Fax Number	:

Provider Business Practice Location Address
First Line	:	3518 CYPRESS TRL APT D208
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-3313
Country	:	US
Telephone Number	:	561-452-8262
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2024
Last Update Date	:	03/19/2024

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