Provider Demographics
NPI:1336322767
Name:JACKSON CORRECTIONAL INSTITUTION
Entity Type:Organization
Organization Name:JACKSON CORRECTIONAL INSTITUTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WARDEN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-569-5260
Mailing Address - Street 1:5563 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:FL
Mailing Address - Zip Code:32445-3129
Mailing Address - Country:US
Mailing Address - Phone:850-569-5260
Mailing Address - Fax:850-569-1013
Practice Address - Street 1:5563 10TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:FL
Practice Address - Zip Code:32445-3129
Practice Address - Country:US
Practice Address - Phone:850-569-5260
Practice Address - Fax:850-569-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1812192261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health