Provider Demographics
NPI:1316770480
Name:JACKSON, BRITTANY CHARLETTE
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:CHARLETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13316 PALMERA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-3502
Mailing Address - Country:US
Mailing Address - Phone:706-495-5907
Mailing Address - Fax:
Practice Address - Street 1:14934 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1632
Practice Address - Country:US
Practice Address - Phone:813-991-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030852363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner