Provider Demographics
NPI:1366122871
Name:JACKSON, REGINA (LPN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 CENTURY RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32443-1928
Mailing Address - Country:US
Mailing Address - Phone:254-426-8975
Mailing Address - Fax:
Practice Address - Street 1:4094 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-5648
Practice Address - Country:US
Practice Address - Phone:850-482-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1240831164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse