Individual
AUDREY LEE FARSON JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
1223 GATEWAY DR STE 1D, MELBOURNE, FL 32901-2607
(321) 729-6166
(321) 722-1237
Mailing address
3300 S FISKE BLVD, ROCKLEDGE, FL 32955-4306
(321) 729-6166
Taxonomy
Speciality
Code
Description
License number
State
363LP2300X
Primary Care Nurse Practitioner
Primary
APRN11026952
FL
363LX0001X
Obstetrics & Gynecology Nurse Practitioner
APRN11026952
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
120782400
—
FL
01
—
SA065
MEDICARE HF
FL
Enumeration date
04/12/2021
Last updated
02/09/2024
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