Basic Information
| Provider Information | |||||||||
| NPI: | 1790765667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045124808 | ||||||||
| FaxNumber: | 7045124838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045124808 | ||||||||
| FaxNumber: | 7045124838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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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 | 208100000X | MT179687 | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | MD13171 | RI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | MD13171 | RI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 2011-00970 | NC | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 5918134 | 05 | NC | MEDICAID | TJ79199 | 05 | RI | MEDICAID | 1790765667 | 05 | NC | MEDICAID | NC1445 | 05 | SC | MEDICAID |