Provider Demographics
NPI:1215171798
Name:JACKSON, KIMBERLY HATCH (ARNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HATCH
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 1:140 SW VIRGINIA CIR
Mailing Address - Street 2:PO BOX 1806
Mailing Address - City:MAYO
Mailing Address - State:FL
Mailing Address - Zip Code:32066-4064
Mailing Address - Country:US
Mailing Address - Phone:386-294-1321
Mailing Address - Fax:386-294-3876
Practice Address - Street 1:140 SW VIRGINIA CIR
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-4064
Practice Address - Country:US
Practice Address - Phone:386-294-1321
Practice Address - Fax:386-294-3876
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9265719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily