Provider Demographics
NPI:1255470209
Name:JACKSON, MARK F (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
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 1:4881 NW 8TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-416-1082
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:3930 US 1 S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7089
Practice Address - Country:US
Practice Address - Phone:352-283-3568
Practice Address - Fax:904-217-3081
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40009207L00000X
FLME142795207LP2900X, 207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000566553OtherANTHEM
OH2872093Medicaid
000000566553OtherANTHEM
KY7100042320Medicaid
000000566553OtherANTHEM
$$$$$$$$$ 611077369OtherHEALTHNET
OH2872093Medicaid
000000566553OtherANTHEM