Individual
MISS DOROTHY MAE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
310 SW 99TH ST, GAINESVILLE, FL 32607-1372
(352) 332-1155
(352) 331-6391
Mailing address
310 SW 99TH ST, GAINESVILLE, FL 32607-1372
(352) 332-1155
(352) 331-6391
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
26-0167133
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
681414096
MEDICAID WAIVER
FL
Enumeration date
02/02/2011
Last updated
02/02/2011
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