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General NPI Number Information
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NPI Number | 1235324658
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Entity Type | Individual
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Provider Name | JOHN B JACKSON
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Gender | Male
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 09/13/2023
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Provider Practice Location Address
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Address Line | 4016 SUN CITY CENTER BLVD
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City | SUN CITY CENTER
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State | FL
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Zip | 33573-5256
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Country | US
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Telephone | 813-634-3301
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Fax |
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Provider Business Mailing Address
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Address Line | 3572 BRODHEAD RD SUITE 201
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City | MONACA
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State | PA
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Zip | 15061-3101
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | ME163263
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD433732
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License Number State | PA
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