Healthcare Provider Details

I. General information

NPI: 1881874584
Provider Name (Legal Business Name): JERRY JAY JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 NORTHSIDE DR
KEY WEST FL
33040-8012
US

IV. Provider business mailing address

3142 NORTHSIDE DR
KEY WEST FL
33040-8012
US

V. Phone/Fax

Practice location:
  • Phone: 305-615-3300
  • Fax:
Mailing address:
  • Phone: 305-615-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME114239
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME114239
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number64653
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberME114239
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: