Provider Demographics
NPI:1417013707
Name:JACKSON CENTER, PA
Entity Type:Organization
Organization Name:JACKSON CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-598-9009
Mailing Address - Street 1:4500 EXECUTIVE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-8908
Mailing Address - Country:US
Mailing Address - Phone:239-598-9009
Mailing Address - Fax:239-598-5009
Practice Address - Street 1:4500 EXECUTIVE DR STE 300
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-8908
Practice Address - Country:US
Practice Address - Phone:239-598-9009
Practice Address - Fax:239-598-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8320Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER