Provider Demographics
NPI:1821038076
Name:JACKSON, BURKE L (MD)
Entity Type:Individual
Prefix:
First Name:BURKE
Middle Name:L
Last Name:JACKSON
Suffix:
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 1:1808 E SILVER SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6921
Mailing Address - Country:US
Mailing Address - Phone:352-291-5000
Mailing Address - Fax:352-291-5004
Practice Address - Street 1:1808 E SILVER SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6921
Practice Address - Country:US
Practice Address - Phone:352-291-5000
Practice Address - Fax:352-291-5004
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041557001Medicaid
FL94201OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL041557001Medicaid
FL94201OtherBLUE CROSS BLUE SHIELD OF FLORIDA