Individual
RICHARD E JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
21260 OLEAN BLVD STE 200, PORT CHARLOTTE, FL 33952-6742
(941) 625-4270
(941) 625-1751
Mailing address
21260 OLEAN BLVD STE 200, PORT CHARLOTTE, FL 33952-6742
(941) 625-4270
(941) 625-1751
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA2962
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
290761500
—
FL
Enumeration date
04/13/2006
Last updated
09/09/2020
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