Provider Demographics
NPI:1003843590
Name:JACKSON, WILLIAM GROVER (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GROVER
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 1:46 TOLL RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:SALISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01952-1435
Mailing Address - Country:US
Mailing Address - Phone:978-462-3009
Mailing Address - Fax:978-462-0177
Practice Address - Street 1:46 TOLL RD
Practice Address - Street 2:UNIT B
Practice Address - City:SALISBURY
Practice Address - State:MA
Practice Address - Zip Code:01952-1435
Practice Address - Country:US
Practice Address - Phone:978-462-3009
Practice Address - Fax:978-462-0177
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57551207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3019152Medicaid
MAJ06202Medicare ID - Type Unspecified
MA3019152Medicaid