MEDICARE: JACKSON JOSAPHAT

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	1722-P.A.	PR

General Provider Information

NPI Number	:	1093490245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON JOSAPHAT

Provider Business Mailing Address
First Line	:	520 JEFFERSON DR UNIT 109
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-9455
Country	:	US
Telephone Number	:	155-124-8277
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 JEFFERSON DR UNIT 109
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-9455
Country	:	US
Telephone Number	:	155-124-8277
Fax Number	:

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

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/25/2023

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Directions to “ JACKSON JOSAPHAT ” Practice Location

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