1346311008 NPI number — MRS. SHARON DENISE JACKSON MS RD CDE

Table of content: MRS. SHARON DENISE JACKSON MS RD CDE (NPI 1346311008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346311008 NPI number — MRS. SHARON DENISE JACKSON MS RD CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SHARON
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS RD CDE
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:
1346311008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 NEWCROFT CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTAPAN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-296-3987
Provider Business Mailing Address Fax Number:
617-713-3438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 BLUE HILLS AVE
Provider Second Line Business Practice Location Address:
MATTAPAN COMMUNITY HEALTH CTR
Provider Business Practice Location Address City Name:
MATTAPAN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-898-9052
Provider Business Practice Location Address Fax Number:
617-713-3438
Provider Enumeration Date:
11/13/2006

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: 133N00000X , with the licence number:  1031 , 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)





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