Provider Demographics
NPI:1598776510
Name:JACKSON, JOSE F
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 N FEDERAL HWY
Mailing Address - Street 2:ORTHOPAEDIC CENTER
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4603
Mailing Address - Country:US
Mailing Address - Phone:954-958-4800
Mailing Address - Fax:954-958-4899
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:ORTHOPAEDIC CENTER
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-958-4800
Practice Address - Fax:954-958-4899
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88256207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267975200Medicaid
FLH94924Medicare UPIN
FL81005ZMedicare ID - Type Unspecified