Provider Demographics
NPI:1487950846
Name:JACKSON, DOROTHY MAE
Entity type:Individual
Prefix:MISS
First Name:DOROTHY
Middle Name:MAE
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 1:310 SW 99TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1372
Mailing Address - Country:US
Mailing Address - Phone:352-332-1155
Mailing Address - Fax:352-331-6391
Practice Address - Street 1:310 SW 99TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1372
Practice Address - Country:US
Practice Address - Phone:352-332-1155
Practice Address - Fax:352-331-6391
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26-0167133172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681414096OtherMEDICAID WAIVER