Healthcare Provider Details

I. General information

NPI: 1639104029
Provider Name (Legal Business Name): EDWARD A JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 LAKE UNDERHILL RD STE 200
ORLANDO FL
32822-8204
US

IV. Provider business mailing address

7975 LAKE UNDERHILL RD STE 200
ORLANDO FL
32822-8204
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6830
  • Fax: 407-303-8659
Mailing address:
  • Phone: 407-303-6830
  • Fax: 407-303-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301046128
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME129390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: