Provider Demographics
NPI:1104609619
Name:JACKSON, MIRANDA LOREN (DNP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOREN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7817 OAK FOREST PL
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-4309
Mailing Address - Country:US
Mailing Address - Phone:850-748-3218
Mailing Address - Fax:
Practice Address - Street 1:98 VARSITY WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32306-0001
Practice Address - Country:US
Practice Address - Phone:850-644-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily