MEDICARE: CHAD EDWIN JACKSON MS, ATC

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	2083S0010X	Sports Medicine (Preventive Medicine) Physician	AL2986	FL

General Provider Information

NPI Number	:	1518484245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD EDWIN JACKSON MS, ATC

Provider Business Mailing Address
First Line	:	618 SE 3RD ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1109
Country	:	US
Telephone Number	:	239-292-7669
Fax Number	:

Provider Business Practice Location Address
First Line	:	14110 SIX MILE CYPRESS PKWY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4314
Country	:	US
Telephone Number	:	239-479-6411
Fax Number	:	239-768-2032

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

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	08/24/2017

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