Provider Demographics
NPI:1598960544
Name:JACKS, CHEAVA L (MD)
Entity Type:Individual
Prefix:
First Name:CHEAVA
Middle Name:L
Last Name:JACKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GABRIELLE LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6190
Mailing Address - Country:US
Mailing Address - Phone:405-229-3733
Mailing Address - Fax:
Practice Address - Street 1:135 AVENUE G
Practice Address - Street 2:
Practice Address - City:APALACHICOLA
Practice Address - State:FL
Practice Address - Zip Code:32320
Practice Address - Country:US
Practice Address - Phone:850-653-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK293731YQ3WMedicare PIN