Individual
DR. JOSEPH C JACKSON JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS,PA
Contact information
Practice address
147 2ND AVE S STE 308, SAINT PETERSBURG, FL 33701-4393
(727) 415-6389
Mailing address
147 2ND AVE S STE 308, SAINT PETERSBURG, FL 33701-4393
(727) 415-6389
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
DN5413
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
075453600
—
FL
05
—
075453601
—
FL
01
—
59-2061906
TAX ID
FL
01
—
85760
BCBS
FL
01
—
DN5413
STATE LICENSE
FL
Enumeration date
04/04/2007
Last updated
08/11/2020
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