Provider Demographics
NPI:1982010674
Name:JACKSON, JOSHUAH
Entity Type:Individual
Prefix:
First Name:JOSHUAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 HOFFNER AVE # 258
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-2331
Mailing Address - Country:US
Mailing Address - Phone:407-502-9111
Mailing Address - Fax:855-947-2792
Practice Address - Street 1:1850 LEE RD STE 122B
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2104
Practice Address - Country:US
Practice Address - Phone:407-502-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 3478171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist