Healthcare Provider Details

I. General information

NPI: 1417013707
Provider Name (Legal Business Name): JACKSON CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 EXECUTIVE DR STE 300
NAPLES FL
34119-8908
US

IV. Provider business mailing address

4500 EXECUTIVE DR STE 300
NAPLES FL
34119-8908
US

V. Phone/Fax

Practice location:
  • Phone: 239-598-9009
  • Fax: 239-598-5009
Mailing address:
  • Phone: 239-598-9009
  • Fax: 239-598-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JON RYAN JACKSON
Title or Position: PRESIDENT
Credential: MD
Phone: 239-598-9009