Provider Demographics
NPI:1447915103
Name:JACKSON, LAZENDRE
Entity type:Individual
Prefix:
First Name:LAZENDRE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 HIBISCUS LN
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-1872
Mailing Address - Country:US
Mailing Address - Phone:561-537-0222
Mailing Address - Fax:
Practice Address - Street 1:1933 HIBISCUS LN
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-1872
Practice Address - Country:US
Practice Address - Phone:561-537-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112157300Medicaid