Basic Information
| Provider Information | |||||||||
| NPI: | 1639373509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON-GALLEGOS | ||||||||
| FirstName: | MASHIRA | ||||||||
| MiddleName: | DENISHA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | MASHIRA | ||||||||
| OtherMiddleName: | DENISHA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135284975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2352 BRUCE B DOWNS BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335449203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139293600 | ||||||||
| FaxNumber: | 8133555901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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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 | 207Q00000X | ME 108584 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 141452 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 141452 | 01 | NC | NC TRAINING LICENSE | OTHER |