Provider Demographics
NPI:1528160181
Name:JACKSON, TERESA A (ARNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 NW 27TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2826
Mailing Address - Country:US
Mailing Address - Phone:305-805-1700
Mailing Address - Fax:305-805-1715
Practice Address - Street 1:20612 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-1469
Practice Address - Country:US
Practice Address - Phone:305-637-6400
Practice Address - Fax:305-636-5155
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2904542363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303067900Medicaid
FL021212500Medicaid