Provider Demographics
NPI:1316939598
Name:JACKSON, JANICE P (ARNP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:P
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 1:2763 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8723
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-322-6184
Practice Address - Street 1:2763 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8723
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-322-6184
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1060102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22320Medicare UPIN
FLU3175ZMedicare ID - Type Unspecified