Provider Demographics
NPI:1104025931
Name:JACKSON FAMILY FOOT & ANKLE CARE, LLC
Entity type:Organization
Organization Name:JACKSON FAMILY FOOT & ANKLE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKESLEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-833-6888
Mailing Address - Street 1:100 W VETERANS HWY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-3435
Mailing Address - Country:US
Mailing Address - Phone:732-833-6888
Mailing Address - Fax:732-833-6280
Practice Address - Street 1:100 W VETERANS HWY
Practice Address - Street 2:SUITE 11
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-3435
Practice Address - Country:US
Practice Address - Phone:732-833-6888
Practice Address - Fax:732-833-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00263900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9052801Medicaid
NJ065985Medicare PIN
NJU84601Medicare UPIN
NJ4845650001Medicare NSC