Healthcare Provider Details

I. General information

NPI: 1033389879
Provider Name (Legal Business Name): JAMIE CRYSTAL JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 TRINITY DR
PENSACOLA FL
32504-5708
US

IV. Provider business mailing address

PO BOX 2699
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7710
  • Fax: 850-416-6729
Mailing address:
  • Phone: 850-475-4686
  • Fax: 850-475-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.203018
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number121872
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberMD.203018
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number121872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: