Provider Demographics
NPI:1275367054
Name:JACKSON, JESSICA LA SHAUN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LA SHAUN
Last Name:JACKSON
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 NE 213TH ST STE 1215
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1267
Mailing Address - Country:US
Mailing Address - Phone:954-489-8815
Mailing Address - Fax:
Practice Address - Street 1:2801 NE 213TH ST STE 1215
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1267
Practice Address - Country:US
Practice Address - Phone:954-489-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11034950363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health