Individual
EVITA B HENDERSON-JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
12902 USF MAGNOLIA DR, TAMPA, FL 33612-9416
(813) 745-7487
Mailing address
12902 USF MAGNOLIA DR, MCC-FA, TAMPA, FL 33612-9416
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
ME104658
FL
390200000X
Student in an Organized Health Care Education/Training Program
TRN9826
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14K4D
BLUE CROSS BLUE SHIELD
FL
Enumeration date
10/16/2007
Last updated
05/15/2012
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