Healthcare Provider Details

I. General information

NPI: 1841243920
Provider Name (Legal Business Name): WILLIAM LEMAR JACKSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 S HICKORY ST
MELBOURNE FL
32901-3278
US

IV. Provider business mailing address

PO BOX 561600
ROCKLEDGE FL
32956-1600
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-4225
  • Fax: 321-434-4247
Mailing address:
  • Phone: 321-434-4656
  • Fax: 321-259-5130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME95860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: