Healthcare Provider Details

I. General information

NPI: 1942135603
Provider Name (Legal Business Name): JEREMIAH CLIFFORD JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1819 SALK AVE
TAVARES FL
32778-4311
US

IV. Provider business mailing address

1819 SALK AVE
TAVARES FL
32778-4311
US

V. Phone/Fax

Practice location:
  • Phone: 352-343-7279
  • Fax: 352-343-1618
Mailing address:
  • Phone: 352-343-7279
  • Fax: 352-343-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: