Provider Demographics
NPI:1023089265
Name:JACKSON, IVOR (MD)
Entity type:Individual
Prefix:DR
First Name:IVOR
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8474
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-8474
Mailing Address - Country:US
Mailing Address - Phone:561-626-9041
Mailing Address - Fax:
Practice Address - Street 1:4600 MILITARY TRAIL
Practice Address - Street 2:SUITE 218
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4813
Practice Address - Country:US
Practice Address - Phone:561-626-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 86546207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006212Medicaid
RI9006212Medicaid
RI001 010323Medicare ID - Type Unspecified