Provider Demographics
NPI:1427658160
Name:JACKSON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JACKSON
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 1:127 TALLULAH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-4163
Mailing Address - Country:US
Mailing Address - Phone:904-707-1943
Mailing Address - Fax:
Practice Address - Street 1:127 TALLULAH AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-4163
Practice Address - Country:US
Practice Address - Phone:904-707-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 343900000X, 347E00000X, 372600000X, 374U00000X
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347E00000XTransportation ServicesTransportation BrokerGroup - Single Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health Aide