Basic Information
| Provider Information | |||||||||
| NPI: | 1023080025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432843400 | ||||||||
| FaxNumber: | 8432843401 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592392220 | ||||||||
| FaxNumber: | 8592396732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 18160 | KY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 64181605 | 05 | KY | MEDICAID |