Provider Demographics
NPI:1427237973
Name:JESSURUN, JACKIE (LPN)
Entity type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:
Last Name:JESSURUN
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 1:111 NW 183RD ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4537
Mailing Address - Country:US
Mailing Address - Phone:305-892-4753
Mailing Address - Fax:305-493-0814
Practice Address - Street 1:111 NW 183RD ST
Practice Address - Street 2:SUITE 500
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4537
Practice Address - Country:US
Practice Address - Phone:305-892-4753
Practice Address - Fax:305-493-0814
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5155284164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse