MEDICARE: TYLER JACKSON

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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1558242008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER JACKSON

Provider Business Mailing Address
First Line	:	555 STOCKTON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-2534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 UNIVERSITY BLVD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4222
Country	:	US
Telephone Number	:	904-702-6156
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2025
Last Update Date	:	09/10/2025

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Directions to “ TYLER JACKSON ” Practice Location

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