Basic Information
| Provider Information | |||||||||
| NPI: | 1033389879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | CRYSTAL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754686 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 TRINITY DR | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325045708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504167710 | ||||||||
| FaxNumber: | 8504166729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.203018 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080C0008X | 121872 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics | 2080C0008X | MD.203018 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics | 208000000X | 121872 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 023386100 | 05 | FL | MEDICAID | 1457299 | 05 | LA | MEDICAID |