Provider Demographics
NPI:1447397021
Name:JACKSON, CONSTANCE L (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 ZEMKE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-5023
Mailing Address - Country:US
Mailing Address - Phone:813-827-9805
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056044A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine