Basic Information
| Provider Information | |||||||||
| NPI: | 1134759855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12564 HIDDEN GARDENS LN | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322583496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042626120 | ||||||||
| FaxNumber: | 9042626120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2020 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | RN9237888 | FL | Y | Agencies | Early Intervention Provider Agency |
No ID Information.