Provider Demographics
NPI:1033389879
Name:JACKSON, JAMIE CRYSTAL (MD)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:CRYSTAL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4686
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:1675 TRINITY DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5708
Practice Address - Country:US
Practice Address - Phone:850-416-7710
Practice Address - Fax:850-416-6729
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203018208000000X, 2080C0008X
FL1218722080C0008X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023386100Medicaid
LA1457299Medicaid