Provider Demographics
NPI:1104157643
Name:JACKSON, JACQUELINE KAY (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1200 NE 55TH BLVD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-2759
Mailing Address - Country:US
Mailing Address - Phone:352-264-8272
Mailing Address - Fax:352-264-8304
Practice Address - Street 1:1621 NE WALDO RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3900
Practice Address - Country:US
Practice Address - Phone:352-264-8272
Practice Address - Fax:352-264-8304
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0058078207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010829000Medicaid