Provider Demographics
NPI:1518484245
Name:JACKSON, CHAD EDWIN (MS, ATC)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:EDWIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1109
Mailing Address - Country:US
Mailing Address - Phone:239-292-7669
Mailing Address - Fax:
Practice Address - Street 1:14110 SIX MILE CYPRESS PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4314
Practice Address - Country:US
Practice Address - Phone:239-479-6411
Practice Address - Fax:239-768-2032
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL29862083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine