Healthcare Provider Details

I. General information

NPI: 1740411503
Provider Name (Legal Business Name): THOMAS JOSEPH JACKSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

291 SOUTHHALL LN STE 201
MAITLAND FL
32751-7290
US

V. Phone/Fax

Practice location:
  • Phone: 407-667-0444
  • Fax: 407-667-4338
Mailing address:
  • Phone: 407-667-0444
  • Fax: 407-667-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6160
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9185036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: