Provider Demographics
NPI:1093724551
Name:JACKSON, JON C (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4544
Mailing Address - Country:US
Mailing Address - Phone:386-761-0050
Mailing Address - Fax:386-761-1167
Practice Address - Street 1:4770 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4544
Practice Address - Country:US
Practice Address - Phone:386-761-0050
Practice Address - Fax:386-761-1167
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME28054174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64353OtherBLUE CROSS BLUE SHIELD
FL013OtherCIGNA
FL013OtherCIGNA
FL64353OtherBLUE CROSS BLUE SHIELD