Provider Demographics
NPI:1366056749
Name:JACKSON, TALESHA MICHELL (APRN)
Entity type:Individual
Prefix:
First Name:TALESHA
Middle Name:MICHELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 MILLENIA BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6052
Mailing Address - Country:US
Mailing Address - Phone:321-427-7887
Mailing Address - Fax:
Practice Address - Street 1:4900 MILLENIA BLVD APT 307
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-6052
Practice Address - Country:US
Practice Address - Phone:321-427-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002223363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care