Provider Demographics
NPI:1740238153
Name:JACKSON, DONALD E JR (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6716 NW 11TH PLACE
Mailing Address - Street 2:STE 200
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4215
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:
Practice Address - Street 1:6716 NW 11TH PLACE
Practice Address - Street 2:STE 200
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4215
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME603172085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054764600Medicaid
FL12766OtherBCBS FL
FL239216OtherAVMED
FLP00328037OtherRAILROAD MEDICARE
FLP00328037OtherRAIL ROAD MEDICARE
FL12766OtherBCBSFL
FL270855OtherAVMED
FLP00316730OtherRAIL ROAD MEDICARE
1740238153OtherTRICARE PRIME
FLP00316730OtherRAILROAD MEDICARE
FLP00316730OtherRAIL ROAD MEDICARE
OH2855030Medicaid
PA102256410 0001Medicaid
FL12766OtherBCBSFL
KY7100108980Medicaid
FL239216OtherAVMED
KY7100108980Medicaid
FL12766UMedicare PIN
1740238153OtherTRICARE PRIME
FLA49764Medicare UPIN
LA1373281Medicaid
FL12766XMedicare PIN