Provider Demographics
NPI:1548412992
Name:JACKSON, JEFFREY LUKE (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LUKE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1677 EAGLE HARBOR PKWY C
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4802
Mailing Address - Country:US
Mailing Address - Phone:904-278-5112
Mailing Address - Fax:904-278-5874
Practice Address - Street 1:1677 EAGLE HARBOR PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4802
Practice Address - Country:US
Practice Address - Phone:904-278-5112
Practice Address - Fax:904-278-5874
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3675213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery