Provider Demographics
NPI:1053927962
Name:MARX, JACKELINE ANDREA (CAA)
Entity type:Individual
Prefix:MRS
First Name:JACKELINE
Middle Name:ANDREA
Last Name:MARX
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5100
Mailing Address - Country:US
Mailing Address - Phone:305-316-1406
Mailing Address - Fax:
Practice Address - Street 1:7700 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4113
Practice Address - Country:US
Practice Address - Phone:800-437-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL615367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant