Provider Demographics
NPI:1346625522
Name:J&E JACKSON ENTERPRISES, PLLC
Entity Type:Organization
Organization Name:J&E JACKSON ENTERPRISES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-704-1807
Mailing Address - Street 1:1677 EAGLE HARBOR PKWY # C
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4802
Mailing Address - Country:US
Mailing Address - Phone:904-278-5112
Mailing Address - Fax:
Practice Address - Street 1:1677 EAGLE HARBOR PKWY # C
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4802
Practice Address - Country:US
Practice Address - Phone:904-278-5112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3484261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD5660OtherMEDICARE PTAN