Provider Demographics
NPI:1538557608
Name:JDPREMIUM HEALTHCARE, LLC
Entity type:Organization
Organization Name:JDPREMIUM HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LADAYSHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:850-455-1252
Mailing Address - Street 1:14 W JORDAN ST STE 1J
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1734
Mailing Address - Country:US
Mailing Address - Phone:850-455-1252
Mailing Address - Fax:844-683-8754
Practice Address - Street 1:14 W JORDAN ST STE 1J
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1734
Practice Address - Country:US
Practice Address - Phone:850-455-1252
Practice Address - Fax:844-683-8754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163W00000X, 207Q00000X
FLME57721208D00000X
FLARNP9361683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015085700Medicaid
FLIF368AMedicare PIN