Provider Demographics
NPI:1225598865
Name:JACKSON, JORDAN VAN (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:VAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10762 PLEASANT KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3667
Mailing Address - Country:US
Mailing Address - Phone:713-447-0122
Mailing Address - Fax:
Practice Address - Street 1:4016 SUN CITY CENTER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5256
Practice Address - Country:US
Practice Address - Phone:813-634-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20918207R00000X, 207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program