Provider Demographics
NPI:1841091220
Name:JACKSON MEDICAL OFFICE LLC
Entity type:Organization
Organization Name:JACKSON MEDICAL OFFICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:AMAYA
Authorized Official - Suffix:
Authorized Official - Credentials:ME
Authorized Official - Phone:728-205-7604
Mailing Address - Street 1:730 NW 107TH AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3104
Mailing Address - Country:US
Mailing Address - Phone:728-205-7604
Mailing Address - Fax:305-341-3910
Practice Address - Street 1:730 NW 107TH AVE STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3104
Practice Address - Country:US
Practice Address - Phone:728-205-7604
Practice Address - Fax:305-341-3910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MEDICAL OFFICE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-21
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center