Provider Demographics
NPI:1033155106
Name:JACKSON, AMY MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 MAGUIRE RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4797
Mailing Address - Country:US
Mailing Address - Phone:407-635-3080
Mailing Address - Fax:407-636-7804
Practice Address - Street 1:2731 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4797
Practice Address - Country:US
Practice Address - Phone:407-635-3080
Practice Address - Fax:407-636-7804
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009067700Medicaid
FL91403YMedicare PIN