Provider Demographics
NPI:1285085357
Name:JACKSON, WESLEY ALEXANDER
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:ALEXANDER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:WESLEY
Other - Middle Name:ALEXANDER
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMP
Mailing Address - Street 1:5911 TIMUQUANA RD UNIT 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7897
Mailing Address - Country:US
Mailing Address - Phone:904-251-5053
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:1361 13TH AVE S STE 120
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3260
Practice Address - Country:US
Practice Address - Phone:904-241-2655
Practice Address - Fax:904-249-2425
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006736213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASC006736OtherPENNSYLVANIA DEPARTMENT OF STATE