MEDICARE: JACKSON MEDICAL CENTER CORP

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	208D00000X	General Practice Physician	HCC6855	FL

General Provider Information

NPI Number	:	1306892179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MEDICAL CENTER CORP

Provider Business Mailing Address
First Line	:	138 NE 1ST AVE
Second Line	:	2 FLOOR
City	:	MIAMI
State	:	FL
Zip	:	33132-2106
Country	:	US
Telephone Number	:	305-416-0014
Fax Number	:	305-416-0013

Provider Business Practice Location Address
First Line	:	138 NE 1ST AVE
Second Line	:	2 FLOOR
City	:	MIAMI
State	:	FL
Zip	:	33132-2106
Country	:	US
Telephone Number	:	305-416-0014
Fax Number	:	305-416-0013

Authorized Official
Title or Position	:	OWNER
Name	:	JORGE L LEON
Credential	:
Telephone Number	:	305-416-0014

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	08/22/2020

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Directions to “JACKSON MEDICAL CENTER CORP ” Practice Location

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