Provider Demographics
NPI:1679971667
Name:JACKSON, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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 1:1501 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-2008
Mailing Address - Country:US
Mailing Address - Phone:727-896-8686
Mailing Address - Fax:727-898-9596
Practice Address - Street 1:1501 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-2008
Practice Address - Country:US
Practice Address - Phone:727-896-8686
Practice Address - Fax:727-898-9596
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other