Basic Information
| Provider Information | |||||||||
| NPI: | 1336152073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1621 COLLINS AVE APT 903 | ||||||||
| Address2: | |||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331393142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055359962 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055856334 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MENA | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3055359962 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 20652 | FL | Y | Hospitals | General Acute Care Hospital |
No ID Information.