Provider Demographics
NPI:1639104029
Name:JACKSON, EDWARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7975 LAKE UNDERHILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8204
Mailing Address - Country:US
Mailing Address - Phone:407-303-6830
Mailing Address - Fax:407-303-8659
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8204
Practice Address - Country:US
Practice Address - Phone:407-303-6830
Practice Address - Fax:407-303-8659
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046128207Q00000X
FLME129390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101977OtherGREAT LAKES HEALTH PLAN
MI381870664OtherPRIORITY HEALTH
MI381870664OtherPRIVATE HEALTHCARE SYSTE
MI381870664112OtherCOMMUNITY CHOICE MICHIGAN
MI0730985OtherBCBSM PIN
MI381870664OtherPPOM
MI080G376200OtherBCBSM GROUP NUMBER
MI1639104029Medicaid
MIEJ046128OtherLICENSE
MI0G37620004OtherRAILROAD MEDICARE
MI381870664OtherHEALTH CARE ALLIANCE POOL
MI4045995OtherAETNA
MI381870664112OtherCOMMUNITY CHOICE MICHIGAN
MI381870664OtherPRIVATE HEALTHCARE SYSTE