Basic Information
| Provider Information | |||||||||
| NPI: | 1437354339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GERARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8135284975 | ||||||||
| Practice Location | |||||||||
| Address1: | 2352 BRUCE B DOWNS BLVD STE 205 | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335449203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139917416 | ||||||||
| FaxNumber: | 8133555097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME110404 | FL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | ME110404 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 004120900 | 05 | FL | MEDICAID | P01024246 | 01 | FL | RR MEDICARE | OTHER |