Provider Demographics
NPI:1932527942
Name:MCKAY, JACK EDWARD
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:MCKAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 MAR WALT DR UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6637
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-863-8085
Practice Address - Street 1:1034 MAR WALT DR UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6637
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-863-8085
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME139390207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14417668OtherCAQH
FL53WFAOtherBCBS FL
FL801769Medicaid