Basic Information
| Provider Information | |||||||||
| NPI: | 1184626012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARIANNE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 6864 | NH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | MD0574536 | 01 | FEDERAL DEA# | OTHER | POOO91565 | 01 | RAILROAD MEDICARE | OTHER | 30203596 | 05 | NH | MEDICAID | 0100920Y0NH02 | 01 | NH | ANTHEM BC/BS | OTHER | 6236954 | 01 | NH | CIGNA HEALTHCARE | OTHER | 5830418 | 01 | AETNA GROUP | OTHER |