Healthcare Provider Details

I. General information

NPI: 1295951374
Provider Name (Legal Business Name): ROOSEVELT T JACKSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W 20TH ST STE 100
RIVIERA BEACH FL
33404-6155
US

IV. Provider business mailing address

133 N STATE ROAD 7
PLANTATION FL
33317-3100
US

V. Phone/Fax

Practice location:
  • Phone: 561-510-0471
  • Fax: 561-331-2715
Mailing address:
  • Phone: 754-244-5132
  • Fax: 866-510-7555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME45529
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME45529
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME45529
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME45529
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: