=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821038076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BURKE L JACKSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 02/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1808 E SILVER SPRINGS BLVD
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34470-6921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-291-5000
-----------------------------------------------------
Fax | 352-291-5004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 E SILVER SPRINGS BLVD
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34470-6921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-291-5000
-----------------------------------------------------
Fax | 352-291-5004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME38870
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------