Basic Information
Provider Information | |||||||||
NPI: | 1124019369 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 346 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137902580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077298156 | ||||||||
FaxNumber: | 6077292209 | ||||||||
Practice Location | |||||||||
Address1: | 33 MITCHELL AVE | ||||||||
Address2: | SUITE G50 | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139031619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077712220 | ||||||||
FaxNumber: | 6077712225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2005 | ||||||||
LastUpdateDate: | 11/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 005302 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 02407216 | 05 | NY |   | MEDICAID |