1770707093 NPI number — EVELYN DIANE JACKSON M.D.

Table of content: EVELYN DIANE JACKSON M.D. (NPI 1770707093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770707093 NPI number — EVELYN DIANE JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
EVELYN
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
EVELYN
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1770707093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3416 OLANDWOOD CT
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
OLNEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20832-1372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-774-5600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3416 OLANDWOOD CT
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
OLNEY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20832-1372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-774-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2007

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: 207R00000X , with the licence number:  D25947 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 25560-1002 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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