# NORTH OKALOOSA CLINIC CORP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** North Okaloosa Clinic Corp, North Okaloosa Physicians Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1558930313
- **Authorized official:** JENNIFER L JACKSON (SR DIR PROV ENROLLMENT & ONBOARDING)
- **Authorized official phone:** (615) 465-3334

## Contact information

- **Practice address:** 131 E REDSTONE AVE STE 105, CRESTVIEW, FL 32539-5355
- **Practice address phone:** (850) 398-8725
- **Practice address fax:** (850) 398-8727
- **Mailing address:** PO BOX 689022, FRANKLIN, TN 37068-9022
- **Mailing address phone:** (615) 465-7211
- **Mailing address fax:** (615) 628-6877

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | — |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 06/24/2021
- **Last updated:** 05/14/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 273693408 | — | FL |