Basic Information
| Provider Information | |||||||||
| NPI: | 1598133571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN, FA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 1ST AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045254316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 1ST AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045254316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2015 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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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 | 163WX0800X | 60256 | WV | Y | Nursing Service Providers | Registered Nurse | Orthopedic | 163WX0800X | 398466 | OH | N | Nursing Service Providers | Registered Nurse | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 352265 | 05 | OH | MEDICAID | 0010681000 | 05 | WV | MEDICAID |