Basic Information
| Provider Information | |||||||||
| NPI: | 1235324658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3572 BRODHEAD RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MONACA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150613101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 DUTCH RIDGE RD | ||||||||
| Address2: | DEPARTMENT OF RADIOLOGY | ||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150099727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247734567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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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 | 2085R0202X | MD433732 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.