1952338337 NPI number — KEITH JACKSON MPT

Table of content: KEITH JACKSON MPT (NPI 1952338337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952338337 NPI number — KEITH JACKSON MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
KEITH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
M

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:
1952338337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1812 MARSH RD
Provider Second Line Business Practice Location Address:
STORE 505
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19810-4581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-475-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  21348 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: J1-0001883 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50700032 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5070-0032 . This is a "NCA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64343601 . This is a "CARE FIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 246555 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64343601 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1530795 . This is a "PABS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2342330000 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".




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