MEDICARE: MORGAN JACKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110007501	VA
2	363A00000X	Physician Assistant	PA9117269	FL

General Provider Information

NPI Number	:	1073075453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MORGAN JACKSON PA-C

Provider Business Mailing Address
First Line	:	11350 MCCORMICK RD
Second Line	:	EXECUTIVE PLAZA 1, STE. 501
City	:	HUNT VALLEY
State	:	MD
Zip	:	21031
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	695 CONE PARK CT
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3755
Country	:	US
Telephone Number	:	321-453-3360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2019
Last Update Date	:	10/13/2023

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