Provider Demographics
NPI:1710109756
Name:JOSEPH C. JACKSON, JR., DDS, PA
Entity Type:Organization
Organization Name:JOSEPH C. JACKSON, JR., DDS, PA
Other - Org Name:JACKSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-397-0353
Mailing Address - Street 1:8250 BRYAN DAIRY RD
Mailing Address - Street 2:#325
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1353
Mailing Address - Country:US
Mailing Address - Phone:727-397-0353
Mailing Address - Fax:727-397-5773
Practice Address - Street 1:8250 BRYAN DAIRY RD
Practice Address - Street 2:#325
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33777-1353
Practice Address - Country:US
Practice Address - Phone:727-397-0353
Practice Address - Fax:727-397-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN54131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN5413OtherSTATE LICENSE
FL85760OtherBCBS
FL85760OtherBCBS