1922047612 NPI number — MR. ROBERT P JACKMAN MD

Table of content: MELISSA EHRMAN (NPI 1245818152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922047612 NPI number — MR. ROBERT P JACKMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKMAN
Provider First Name:
ROBERT
Provider Middle Name:
P
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1922047612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2865 DAGGETT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97601-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-274-8400
Provider Business Mailing Address Fax Number:
541-274-8405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2821 DAGGETT AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97601-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-274-8400
Provider Business Practice Location Address Fax Number:
541-274-8405
Provider Enumeration Date:
06/06/2006

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: 207Q00000X , with the licence number:  MD22734 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H64487 . This is a "CHAMPUS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: H073533 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 286522 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 059575000 . This is a "BCBS OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 140008075 . This is a "RAILROAD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: XPY200005 . This is a "CALIFORNIA WELFARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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