Provider Demographics
NPI:1235324658
Name:JACKSON, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 BRODHEAD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4016 SUN CITY CENTER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5256
Practice Address - Country:US
Practice Address - Phone:813-634-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1632632085R0202X
PAMD4337322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAJA2052605OtherHIGHMARK BLUE SHIELD NUMBER
PA000000273808OtherUNISON
PA1022258530002Medicaid
PA000000273808OtherUNISON
PA420437Medicare PIN