Provider Demographics
NPI:1801439542
Name:JACKSON, ANNA PAVLOVNA (PNP-PC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:PAVLOVNA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11327 OKEECHOBEE BLVD, STE 2 & 3
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470
Mailing Address - Country:US
Mailing Address - Phone:561-340-1615
Mailing Address - Fax:561-340-4026
Practice Address - Street 1:11327 OKEECHOBEE BLVD, STE 2 & 3
Practice Address - Street 2:MEDICAL MALL 2, SUITE 224
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470
Practice Address - Country:US
Practice Address - Phone:561-340-1615
Practice Address - Fax:561-340-4026
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004601363LP0200X
FLAPRB11004601207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics