Provider Demographics
NPI:1952338485
Name:JACKSON, DAVID M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 ASTOR ST
Mailing Address - Street 2:PA2
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5668
Mailing Address - Country:US
Mailing Address - Phone:904-305-3221
Mailing Address - Fax:
Practice Address - Street 1:1133 SAXON BLVD
Practice Address - Street 2:PROMPT CARE
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-0000
Practice Address - Country:US
Practice Address - Phone:904-305-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01108408409363AM0700X
FL9104510363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003373900Medicaid
Y06YYOtherBCBS
FLEW423ZMedicare PIN
Y06YYOtherBCBS