Provider Demographics
NPI:1750513016
Name:JACKSON DIAGNOSTIC IMAGING, INC
Entity type:Organization
Organization Name:JACKSON DIAGNOSTIC IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SARELYN
Authorized Official - Middle Name:BERTINA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-299-2424
Mailing Address - Street 1:65 3RD ST NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4670
Mailing Address - Country:US
Mailing Address - Phone:863-299-2424
Mailing Address - Fax:863-299-4848
Practice Address - Street 1:65 3RD ST NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4670
Practice Address - Country:US
Practice Address - Phone:863-299-2424
Practice Address - Fax:863-299-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile