Provider Demographics
NPI:1679630842
Name:JACKSON, JADE (LDO)
Entity Type:Individual
Prefix:MRS
First Name:JADE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 PALM COAST PKWY SW
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4700
Mailing Address - Country:US
Mailing Address - Phone:386-446-4210
Mailing Address - Fax:386-445-7309
Practice Address - Street 1:1240 PALM COAST PKWY SW
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4700
Practice Address - Country:US
Practice Address - Phone:386-446-4210
Practice Address - Fax:386-445-7309
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5189156FX1800X
FLDO1284156FX1800X
FLDO3668156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOP0463OtherEYE-MED
FL630073100Medicaid