Healthcare Provider Details

I. General information

NPI: 1053730416
Provider Name (Legal Business Name): KASEY JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 S ALAFAYA TRL STE 400
ORLANDO FL
32828-8956
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 407-249-1234
  • Fax: 407-249-1755
Mailing address:
  • Phone: 407-249-1234
  • Fax: 407-249-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61971
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number61971
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberR3536
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME176093
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: