Provider Demographics
NPI:1023463429
Name:JACKSON MEDICAL ENTERPRISE
Entity type:Organization
Organization Name:JACKSON MEDICAL ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-207-0948
Mailing Address - Street 1:2263 CAMPESTRE TER
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-3358
Mailing Address - Country:US
Mailing Address - Phone:239-207-0948
Mailing Address - Fax:
Practice Address - Street 1:4800 ASTON GARDENS WAY
Practice Address - Street 2:MEDICAL DIRECTOR'S OFFICE
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3501
Practice Address - Country:US
Practice Address - Phone:239-330-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 104632310400000X, 314000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility