Provider Demographics
NPI:1295951374
Name:JACKSON, ROOSEVELT T JR (MD)
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:T
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-3100
Mailing Address - Country:US
Mailing Address - Phone:754-244-5132
Mailing Address - Fax:866-510-7555
Practice Address - Street 1:31 W 20TH ST STE 100
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-6155
Practice Address - Country:US
Practice Address - Phone:561-510-0471
Practice Address - Fax:561-331-2715
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45529207Q00000X, 207W00000X, 207P00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043150800Medicaid
FLC08787Medicare UPIN