Provider Demographics
NPI:1033168612
Name:JACKSON ANESTHESIA ASSOCIATES INC
Entity Type:Organization
Organization Name:JACKSON ANESTHESIA ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA ARNP
Authorized Official - Phone:850-482-7200
Mailing Address - Street 1:3024 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2125
Mailing Address - Country:US
Mailing Address - Phone:850-482-7200
Mailing Address - Fax:
Practice Address - Street 1:3024 4TH ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2125
Practice Address - Country:US
Practice Address - Phone:850-482-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0188Medicare ID - Type Unspecified