Healthcare Provider Details

I. General information

NPI: 1023463429
Provider Name (Legal Business Name): JACKSON MEDICAL ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 ASTON GARDENS WAY MEDICAL DIRECTOR'S OFFICE
NAPLES FL
34109-3501
US

IV. Provider business mailing address

2263 CAMPESTRE TER
NAPLES FL
34119-3358
US

V. Phone/Fax

Practice location:
  • Phone: 239-330-1301
  • Fax:
Mailing address:
  • Phone: 239-207-0948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberME 104632
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberME 104632
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberME 104632
License Number StateFL

VIII. Authorized Official

Name: MALIA M JACKSON RODRIGUEZ
Title or Position: OWNER
Credential: M.D.
Phone: 239-207-0948