Provider Demographics
NPI:1558741652
Name:JACKSON, ANTHONY (CAC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-2286
Mailing Address - Country:US
Mailing Address - Phone:954-663-8045
Mailing Address - Fax:
Practice Address - Street 1:2000 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-2286
Practice Address - Country:US
Practice Address - Phone:954-663-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator