Healthcare Provider Details

I. General information

NPI: 1225598865
Provider Name (Legal Business Name): JORDAN VAN JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 SUN CITY CENTER BLVD
SUN CITY CENTER FL
33573-5256
US

IV. Provider business mailing address

10762 PLEASANT KNOLL DR
TAMPA FL
33647-3667
US

V. Phone/Fax

Practice location:
  • Phone: 813-634-3301
  • Fax:
Mailing address:
  • Phone: 713-447-0122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS20918
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberOS20918
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: