Roosevelt T Jackson Jr., M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

ME45529 Issued in FL

Practice address

31 W 20TH St Ste 100
Riviera Beach, FL 33404-6155

Phone

(561) 510-0471

Fax

(561) 331-2715

NPI assigned

Apr 17, 2007

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 4

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Doctor of Medicine

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Integrated Healthcare Systems Riviera Inc

  • Professional Counselor
  • Spartanburg, SC
  • NPI 1346185527
  NPD (past)

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

{
    "created_epoch": "1176768000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1545004800000",
    "number": "1295951374",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "133 N STATE ROAD 7",
            "city": "PLANTATION",
            "state": "FL",
            "postal_code": "333173100",
            "telephone_number": "754-244-5132",
            "fax_number": "866-510-7555"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "31 W 20TH ST STE 100",
            "city": "RIVIERA BEACH",
            "state": "FL",
            "postal_code": "334046155",
            "telephone_number": "561-510-0471",
            "fax_number": "561-331-2715"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "133 N State Road 7",
            "address_purpose": "LOCATION",
            "city": "Plantation",
            "state": "FL",
            "postal_code": "33317",
            "country_code": "US",
            "telephone_number": "954-587-7075",
            "fax_number": "954-587-7076",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "ROOSEVELT",
        "middle_name": "T",
        "name_suffix": "Jr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-17",
        "last_updated": "2018-12-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "ME45529",
            "primary": true
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "FL",
            "license": "ME45529",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "FL",
            "license": "ME45529",
            "primary": false
        },
        {
            "code": "207QA0401X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "FL",
            "license": "ME45529",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "043150800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ivan Ivardic, PSYCHOLOGIST
• Danyelle Jackson
• Jonathan Levi Jackson, PHARMD
• Lazendre Jackson
• Lillie Pearl Jackson, LPN
• Shari Jackson, APRN
• Shenelle Jacobs
• Roxana Jafari
• Leslie S Jaworski, LMHC
• Robenson Jean Claude

• Family Medicine Physician in Riviera Beach, FL
• Providers in Riviera Beach, FL by specialty
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.