Provider Demographics
NPI:1922184258
Name:RICKETTS, JACK E (MD OBGYN)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:MD OBGYN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8333 N DAVIS HWY FL 7
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-969-2038
Mailing Address - Fax:850-969-2037
Practice Address - Street 1:8333 N DAVIS HWY FL 7
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-494-4600
Practice Address - Fax:850-969-2037
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5C65207V00000X
FLME119487207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202688602Medicaid
MO202688602Medicaid
MO000004773Medicare PIN