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Individual

JULLIET JACKSON

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F

Contact information

Practice address
17345 EDGEWATER DR, PORT CHARLOTTE, FL 33948-2343
(941) 766-0175
Mailing address
17345 EDGEWATER DR, PORT CHARLOTTE, FL 33948-2343
(941) 766-0175

Taxonomy

Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
6905617
FL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
142038100
FL
Enumeration date
11/20/2013
Last updated
11/20/2013
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