MEDICARE: JACKSON MEDICAL ENTERPRISE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	ME 104632	FL
2	314000000X	Skilled Nursing Facility	ME 104632	FL
3	261QP2300X	Primary Care Clinic/Center	ME 104632	FL

General Provider Information

NPI Number	:	1023463429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MEDICAL ENTERPRISE

Provider Business Mailing Address
First Line	:	2263 CAMPESTRE TER
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34119-3358
Country	:	US
Telephone Number	:	239-207-0948
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 ASTON GARDENS WAY
Second Line	:	MEDICAL DIRECTOR'S OFFICE
City	:	NAPLES
State	:	FL
Zip	:	34109-3501
Country	:	US
Telephone Number	:	239-330-1301
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MALIA M JACKSON RODRIGUEZ
Credential	:	M.D.
Telephone Number	:	239-207-0948

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	05/04/2016

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Directions to “JACKSON MEDICAL ENTERPRISE ” Practice Location

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