Provider Demographics
NPI:1225565310
Name:JACKSON, CRYSTAL LOUISE (MSN, APRN, WHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:
Credentials:MSN, APRN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 SAINT LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-6722
Mailing Address - Country:US
Mailing Address - Phone:772-240-3159
Mailing Address - Fax:
Practice Address - Street 1:2700 PGA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2958
Practice Address - Country:US
Practice Address - Phone:561-630-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9437936163W00000X
FLAPRN11037866363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11037866OtherAPRN
FLRN9437936OtherRN