Provider Demographics
NPI:1881874584
Name:JACKSON, JERRY JAY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:JAY
Last Name:JACKSON
Suffix:
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 1:3134 NORTHSIDE DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-8004
Mailing Address - Country:US
Mailing Address - Phone:305-809-5278
Mailing Address - Fax:
Practice Address - Street 1:3134 NORTHSIDE DR
Practice Address - Street 2:BLDG B
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-8004
Practice Address - Country:US
Practice Address - Phone:305-809-5278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114239207RI0200X
GA64653207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARES0000Medicare UPIN