Provider Demographics
NPI:1467423632
Name:JACKSON, BRYCE V (MD)
Entity Type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:V
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 1:1937 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4543
Mailing Address - Country:US
Mailing Address - Phone:850-784-6877
Mailing Address - Fax:850-785-5346
Practice Address - Street 1:1937 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4543
Practice Address - Country:US
Practice Address - Phone:850-784-6877
Practice Address - Fax:850-785-5346
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48532207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043532500Medicaid
FL03638OtherBCBS OF FL
FL03638OtherBCBS OF FL
FL592870988OtherTAX ID NUMBER
FL03638OtherBCBS OF FL