Provider Demographics
NPI:1114398427
Name:DR JOE A JACKSON, MD PLLC
Entity Type:Organization
Organization Name:DR JOE A JACKSON, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-469-1330
Mailing Address - Street 1:224 E GARDEN ST
Mailing Address - Street 2:SUITE 5B BOX J16
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-6068
Mailing Address - Country:US
Mailing Address - Phone:850-469-1330
Mailing Address - Fax:850-469-1554
Practice Address - Street 1:224 E GARDEN ST
Practice Address - Street 2:SUITE 5B BOX J16
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-6068
Practice Address - Country:US
Practice Address - Phone:850-469-1330
Practice Address - Fax:850-469-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL856132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013024Medicaid
MSD00683Medicare UPIN