Provider Demographics
NPI:1831124510
Name:JACKLER, IRA MICHAEL
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:MICHAEL
Last Name:JACKLER
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:PO BOX 56917
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-6917
Mailing Address - Country:US
Mailing Address - Phone:904-739-6666
Mailing Address - Fax:904-739-1009
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 207
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4246
Practice Address - Country:US
Practice Address - Phone:904-739-6666
Practice Address - Fax:904-739-1009
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0022114207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15314OtherBCBSFL
FLD52515Medicare UPIN
FL15314ZMedicare ID - Type Unspecified