Healthcare Provider Details

I. General information

NPI: 1093724551
Provider Name (Legal Business Name): JON C JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 S RIDGEWOOD AVE
PORT ORANGE FL
32127-4544
US

IV. Provider business mailing address

4770 S RIDGEWOOD AVE
PORT ORANGE FL
32127-4544
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-0050
  • Fax: 386-761-1167
Mailing address:
  • Phone: 386-761-0050
  • Fax: 386-761-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME28054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: