Provider Demographics
NPI:1205174695
Name:JACKSONVILLE PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:JACKSONVILLE PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:W
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-619-2703
Mailing Address - Street 1:7860 GATE PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7280
Mailing Address - Country:US
Mailing Address - Phone:904-619-2703
Mailing Address - Fax:904-619-2837
Practice Address - Street 1:7860 GATE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7280
Practice Address - Country:US
Practice Address - Phone:904-619-2703
Practice Address - Fax:904-619-2837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9278608363L00000X
FLME88018207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty