Provider Demographics
NPI:1003770009
Name:JACKSON, ANTOINIQUE
Entity type:Individual
Prefix:
First Name:ANTOINIQUE
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 1:1622 JORK RD APT 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2487
Mailing Address - Country:US
Mailing Address - Phone:904-893-0218
Mailing Address - Fax:
Practice Address - Street 1:1622 JORK RD APT 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2487
Practice Address - Country:US
Practice Address - Phone:904-893-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-13
Last Update Date:2025-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion