Provider Demographics
NPI:1003200601
Name:JACKSON, TREVOR G (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 GRANITE RUN DRIVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6823
Mailing Address - Country:US
Mailing Address - Phone:717-560-4200
Mailing Address - Fax:717-560-4200
Practice Address - Street 1:231 GRANITE RUN DRIVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6823
Practice Address - Country:US
Practice Address - Phone:717-560-4200
Practice Address - Fax:717-560-4200
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD475250207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program