Provider Demographics
NPI:1174587505
Name:JACKSON, RICHARD E (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21260 OLEAN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6742
Mailing Address - Country:US
Mailing Address - Phone:941-625-4270
Mailing Address - Fax:941-625-1751
Practice Address - Street 1:21260 OLEAN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6742
Practice Address - Country:US
Practice Address - Phone:941-625-4270
Practice Address - Fax:941-625-1751
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2962363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290761500Medicaid
S46287Medicare UPIN
FL290761500Medicaid