Healthcare Provider Details

I. General information

NPI: 1295660199
Provider Name (Legal Business Name): FOUNDATIONS FOOT AND ANKLE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 ROBERTS VILLAGE CT STE 801
ST JOHNS FL
32259-9570
US

IV. Provider business mailing address

94 ROBERTS VILLAGE CT STE 801
ST JOHNS FL
32259-9570
US

V. Phone/Fax

Practice location:
  • Phone: 407-435-2965
  • Fax:
Mailing address:
  • Phone: 407-435-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MARIKA JACKSON
Title or Position: OWNER
Credential: DPM
Phone: 407-435-2965