Organization
NORTH OKALOOSA CLINIC CORP
Active
Other names
North Okaloosa Physician Group Pulmono, North Okaloosa Clinic Corp
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER L JACKSON (SR DIR PROV ENROLLMENT & ONBOARDING)
(615) 465-3334
Entity
Organization
Contact information
Practice address
550 REDSTONE AVE W STE 490, CRESTVIEW, FL 32536-6457
(850) 689-8321
(850) 689-8322
Mailing address
PO BOX 689022, FRANKLIN, TN 37068-9022
(615) 465-7211
(615) 628-6877
Taxonomy
Speciality
Code
Description
License number
State
207RP1001X
Pulmonary Disease Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363AM0700X
Medical Physician Assistant
—
—
363AS0400X
Surgical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
273693405
—
FL
Enumeration date
06/23/2021
Last updated
03/18/2022
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