Healthcare Provider Details

I. General information

NPI: 1023089265
Provider Name (Legal Business Name): IVOR JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MILITARY TRAIL SUITE 218
JUPITER FL
33458-4813
US

IV. Provider business mailing address

PO BOX 8474
JUPITER FL
33468-8474
US

V. Phone/Fax

Practice location:
  • Phone: 561-626-9041
  • Fax:
Mailing address:
  • Phone: 561-626-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME 86546
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: