Provider Demographics
NPI:1013594878
Name:JACKSON, ERICK
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-3027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 6TH ST SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-2617
Practice Address - Country:US
Practice Address - Phone:202-469-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty