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General NPI Number Information
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NPI Number | 1417013707
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Entity Type | Organization
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Legal Business Name | JACKSON CENTER, PA
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 02/17/2023
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Provider Practice Location Address
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Address Line | 4500 EXECUTIVE DR STE 300
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City | NAPLES
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State | FL
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Zip | 34119-8908
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Country | US
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Telephone | 239-598-9009
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Fax | 239-598-5009
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Provider Business Mailing Address
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Address Line | 4500 EXECUTIVE DR STE 300
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City | NAPLES
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State | FL
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Zip | 34119-8908
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Country | US
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Telephone | 239-598-9009
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Fax | 239-598-5009
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JON RYAN JACKSON
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Credential | MD
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Telephone | 239-598-9009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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