1821141219 NPI number — WILLIAM G JACKSON, M.D., LLC

Table of content: (NPI 1821141219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821141219 NPI number — WILLIAM G JACKSON, M.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM G JACKSON, M.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821141219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46 TOLL RD
Provider Second Line Business Mailing Address:
UNIT B
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01952-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-462-3009
Provider Business Mailing Address Fax Number:
978-462-0177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 TOLL RD
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01952-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-462-3009
Provider Business Practice Location Address Fax Number:
978-462-0177
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
978-462-3009

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  57551 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9751301 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M18969 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 30213523 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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