Provider Demographics
NPI:1396398608
Name:JACKSON REEF
Entity Type:Organization
Organization Name:JACKSON REEF
Other - Org Name:LIFE IS KETAFUL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CRNA
Authorized Official - Phone:386-487-4673
Mailing Address - Street 1:495 S NOVA RD STE 101A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8444
Mailing Address - Country:US
Mailing Address - Phone:386-487-4673
Mailing Address - Fax:855-829-5770
Practice Address - Street 1:495 S NOVA RD STE 101A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8444
Practice Address - Country:US
Practice Address - Phone:386-487-4673
Practice Address - Fax:855-829-5770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service