NPIMap

Organization Active NPI

North Okaloosa Clinic Corp

  • Pulmonary Disease Physician
  • Crestview, FL
National Provider Identifier
1144899014
Registry record updated Mar 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pulmonary Disease PhysicianTaxonomy code 207RP1001X
Legal business name
NORTH OKALOOSA CLINIC CORP
Practice address
550 Redstone Ave W Ste 490
Crestview, FL 32536-6457
Phone
(850) 689-8321
Fax
(850) 689-8322
NPI assigned
Jun 23, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer L Jackson
Title
Sr Dir Prov Enrollment & Onboarding
Phone
(615) 465-3334

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Pulmonary Disease PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RP1001X Primary
Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363A00000X
Medical Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363AM0700X
Surgical Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363AS0400X

Addresses

Primary practice location

550 Redstone Ave W Ste 490
Crestview, FL 32536-6457

Mailing address

PO Box 689022
Franklin, TN 37068-9022
Phone (615) 465-7211

Other identifiers 1

IdentifierTypeStateIssuer
273693405MedicaidFL

Other names 2

  • North Okaloosa Clinic Corp Doing business as
  • North Okaloosa Physician Group Pulmono Doing business as

National Provider Directory

National Provider Directory
Tax ID family
North Okaloosa Clinic Corp12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

550 Redstone Ave W
Ste 490
Crestview, FL 32536
Phone (850) 689-8321

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1624406400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647561600000",
    "number": "1144899014",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 689022",
            "city": "FRANKLIN",
            "state": "TN",
            "postal_code": "370689022",
            "telephone_number": "615-465-7211",
            "fax_number": "615-628-6877"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "550 REDSTONE AVE W STE 490",
            "city": "CRESTVIEW",
            "state": "FL",
            "postal_code": "325366457",
            "telephone_number": "850-689-8321",
            "fax_number": "850-689-8322"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH OKALOOSA CLINIC CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-23",
        "last_updated": "2022-03-18",
        "certification_date": "2022-03-18",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "SR DIR PROV ENROLLMENT & ONBOARDING",
        "authorized_official_telephone_number": "615-465-3334"
    },
    "taxonomies": [
        {
            "code": "207RP1001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "273693405",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North Okaloosa Clinic Corp",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "North Okaloosa Physician Group Pulmono",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "North Okaloosa Physician Group Pulmono",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crestview, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.