Provider Demographics
NPI:1821672817
Name:JACKSON, MARIKA LAUREN COLLYMORE (DPM)
Entity type:Individual
Prefix:DR
First Name:MARIKA
Middle Name:LAUREN COLLYMORE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MARIKA
Other - Middle Name:LAUREN
Other - Last Name:COLLYMORE JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:630 JACKSONVILLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3814
Mailing Address - Country:US
Mailing Address - Phone:904-323-0954
Mailing Address - Fax:
Practice Address - Street 1:630 JACKSONVILLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3814
Practice Address - Country:US
Practice Address - Phone:904-323-0954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2025-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4497213E00000X, 213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program