Provider Demographics
NPI:1861738817
Name:JACKSON, RHONDA GARY (ARNP)
Entity type:Individual
Prefix:
First Name:RHONDA
Middle Name:GARY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10420 MCKINLEY DR APT 9312
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6448
Mailing Address - Country:US
Mailing Address - Phone:813-340-5499
Mailing Address - Fax:866-404-2708
Practice Address - Street 1:10420 MCKINLEY DR APT 9312
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6448
Practice Address - Country:US
Practice Address - Phone:813-340-5499
Practice Address - Fax:866-404-2708
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2863432363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01142391OtherRRMCR
FL7857600Medicaid
P01142391OtherRRMCR