Basic Information
| Provider Information | |||||||||
| NPI: | 1922692516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHAUNYALE | ||||||||
| MiddleName: | TIFFANY | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13609 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681545260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028911118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14550 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042716000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9557857 | FL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.