Provider Demographics
NPI:1437354339
Name:JACKSON, MICHAEL GERARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-528-4975
Practice Address - Street 1:2352 BRUCE B DOWNS BLVD STE 205
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9203
Practice Address - Country:US
Practice Address - Phone:813-991-7416
Practice Address - Fax:813-355-5097
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110404207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004120900Medicaid
FLP01024246OtherRR MEDICARE
FL004120900Medicaid
FLFP230Y-TPAMedicare PIN