1114398427 NPI number — DR JOE A JACKSON, MD PLLC

Table of content: GEOFFREY C SCHILLER MSW, LICSW, CMHS (NPI 1124110416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114398427 NPI number — DR JOE A JACKSON, MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR JOE A JACKSON, MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114398427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 E GARDEN ST
Provider Second Line Business Mailing Address:
SUITE 5B BOX J16
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32502-6068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-469-1330
Provider Business Mailing Address Fax Number:
850-469-1554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 E GARDEN ST
Provider Second Line Business Practice Location Address:
SUITE 5B BOX J16
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32502-6068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-469-1330
Provider Business Practice Location Address Fax Number:
850-469-1554
Provider Enumeration Date:
10/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JOE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-469-1330

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  85613 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00013024 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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