Provider Demographics
NPI:1346263449
Name:JACKSON, KIMBERLY T (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N DONNELLY ST
Mailing Address - Street 2:#200
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6966
Mailing Address - Country:US
Mailing Address - Phone:352-735-8231
Mailing Address - Fax:
Practice Address - Street 1:2110 N DONNELLY ST
Practice Address - Street 2:#200
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6966
Practice Address - Country:US
Practice Address - Phone:352-735-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I52040Medicare UPIN
FL42053YMedicare PIN