Provider Demographics
NPI:1447976071
Name:ETIENNE, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2881 NW 68TH LN
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-2041
Mailing Address - Country:US
Mailing Address - Phone:305-834-6850
Mailing Address - Fax:
Practice Address - Street 1:5932 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2010
Practice Address - Country:US
Practice Address - Phone:954-598-2364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF09220203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily