Provider Demographics
NPI:1548672322
Name:LETICIA JACKSON PA
Entity type:Organization
Organization Name:LETICIA JACKSON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:786-624-9333
Mailing Address - Street 1:12973 SW 112TH ST
Mailing Address - Street 2:SUITE 144
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4768
Mailing Address - Country:US
Mailing Address - Phone:786-624-9333
Mailing Address - Fax:
Practice Address - Street 1:12973 SW 112TH ST
Practice Address - Street 2:SUITE 144
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4768
Practice Address - Country:US
Practice Address - Phone:786-624-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3326732363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty