Healthcare Provider Details

I. General information

NPI: 1841556958
Provider Name (Legal Business Name): JACOB MARSHALL GILLIKIN MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RIVERPLACE BLVD STE 2540
JACKSONVILLE FL
32207-9032
US

IV. Provider business mailing address

3926 DANFORTH DR W
JACKSONVILLE FL
32224-2248
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-4030
  • Fax:
Mailing address:
  • Phone: 757-724-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberME128123
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME128123
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: