Provider Demographics
NPI:1386260545
Name:JACKSON, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:2503 BENEVA RD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-3602
Mailing Address - Country:US
Mailing Address - Phone:419-450-9525
Mailing Address - Fax:
Practice Address - Street 1:2503 BENEVA RD UNIT 8
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-3602
Practice Address - Country:US
Practice Address - Phone:419-450-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9441161163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse