Organization
NORTH OKALOOSA CLINIC CORP
Active
Other names
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
127 E REDSTONE AVE STE B, CRESTVIEW, FL 32539-5356
(850) 689-8100
(850) 689-8261
Mailing address
PO BOX 689022, FRANKLIN, TN 37068-9022
(615) 465-7211
(615) 628-6877
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
273693406
—
FL
Enumeration date
06/21/2021
Last updated
03/18/2022
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