Individual
MARDELL JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
197 NW GWEN LAKE AVE, LAKE CITY, FL 32055-3711
(386) 697-9425
Mailing address
PO BOX 2666, LAKE CITY, FL 32056-2666
(386) 697-9425
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
—
—
Other
Enumeration date
08/30/2018
Last updated
08/30/2018
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