Healthcare Provider Details

I. General information

NPI: 1912326513
Provider Name (Legal Business Name): ERIN AUDREY MARIE JACKSON M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE STE 5F
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-1890
  • Fax: 850-416-1891
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME168082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: