Provider Demographics
NPI:1184607541
Name:JACKSON, JOHN JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:111 NW 183RD ST STE 306
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4599
Mailing Address - Country:US
Mailing Address - Phone:305-705-6688
Mailing Address - Fax:305-946-1516
Practice Address - Street 1:111 NW 183RD ST STE 306
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169
Practice Address - Country:US
Practice Address - Phone:305-705-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37656208D00000X
FLME37656208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025035200Medicaid
FL95796Medicare ID - Type Unspecified