Provider Demographics
NPI:1477855831
Name:JACKSON, CHRISTINA ALICIA GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:ALICIA GAIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHRISTINA
Other - Middle Name:ALICIA GAIL
Other - Last Name:POMPEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-729-6166
Mailing Address - Fax:321-722-1237
Practice Address - Street 1:1223 GATEWAY DR STE 1D
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-729-6166
Practice Address - Fax:321-722-1237
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121754207V00000X
MI4301097665207V00000X
KS04-39453207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013524000Medicaid
FL013524000Medicaid