Healthcare Provider Details

I. General information

NPI: 1922184258
Provider Name (Legal Business Name): JACK E RICKETTS MD OBGYN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8333 N DAVIS HWY FL 7
PENSACOLA FL
32514-6050
US

IV. Provider business mailing address

8333 N DAVIS HWY FL 7
PENSACOLA FL
32514-6050
US

V. Phone/Fax

Practice location:
  • Phone: 850-494-4600
  • Fax: 850-969-2037
Mailing address:
  • Phone: 850-969-2038
  • Fax: 850-969-2037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR5C65
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME119487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: