Basic Information
| Provider Information | |||||||||
| NPI: | 1235799875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | VERNITA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10970 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337330970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222110 | ||||||||
| Practice Location | |||||||||
| Address1: | 928 22ND AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337052934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2019 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.