1073075453 NPI number — MORGAN JACKSON PA-C

Table of content: MORGAN JACKSON PA-C (NPI 1073075453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073075453 NPI number — MORGAN JACKSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MORGAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1073075453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11350 MCCORMICK RD
Provider Second Line Business Mailing Address:
EXECUTIVE PLAZA 1, STE. 501
Provider Business Mailing Address City Name:
HUNT VALLEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
695 CONE PARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32952-3755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-453-3360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2019

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: 363A00000X , with the licence number:  0110007501 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9117269 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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