MEDICARE: CHRISTINE A 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	172A00000X	Driver

General Provider Information

NPI Number	:	1447735774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE A JACKSON

Provider Business Mailing Address
First Line	:	2791 BURRI TER
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-6337
Country	:	US
Telephone Number	:	941-445-3021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2791 BURRI TER
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-6337
Country	:	US
Telephone Number	:	941-445-3021
Fax Number	:

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

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	10/02/2018

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