Active NPI
Chad Edwin Jackson, MS, ATC
- Sports Medicine (Preventive Medicine) Physician
- Fort Myers, FL
National Provider Identifier
1518484245
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Sports Medicine (Preventive Medicine) Physician
- License
- AL2986
- Practice address
- 14110 Six Mile Cypress Pkwy
Fort Myers, FL 33912-4314 - Phone
- (239) 479-6411
- Fax
- (239) 768-2032
- NPI assigned
- Aug 24, 2017
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Sports Medicine (Preventive Medicine) Physician | 2083S0010X | AL2986 | FL | Primary |
Addresses
Primary practice location
14110 Six Mile Cypress Pkwy
Fort Myers, FL 33912-4314
Mailing address
618 SE 3Rd St
Cape Coral, FL 33990-1109
Phone (239) 292-7669
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AL2986 | FL | MD | Sports Medicine (Preventive Medicine) Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1503532800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1503532800000",
"number": "1518484245",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "618 SE 3RD ST",
"city": "CAPE CORAL",
"state": "FL",
"postal_code": "339901109",
"telephone_number": "239-292-7669"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14110 SIX MILE CYPRESS PKWY",
"city": "FORT MYERS",
"state": "FL",
"postal_code": "339124314",
"telephone_number": "239-479-6411",
"fax_number": "239-768-2032"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "CHAD",
"middle_name": "EDWIN",
"credential": "MS, ATC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2017-08-24",
"last_updated": "2017-08-24",
"status": "A"
},
"taxonomies": [
{
"code": "2083S0010X",
"taxonomy_group": "",
"desc": "Preventive Medicine, Sports Medicine",
"state": "FL",
"license": "AL2986",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Myers, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.