Basic Information
| Provider Information | |||||||||
| NPI: | 1295792687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 FRIENDSHIP ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018451593 | ||||||||
| FaxNumber: | 4018470650 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 FRIENDSHIP ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018451593 | ||||||||
| FaxNumber: | 4018470650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 04/10/2009 | ||||||||
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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 | 363AM0700X | PA00132 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7006480 | 05 | RI | MEDICAID |