Provider Demographics
NPI:1043313026
Name:JACKSON, RAYMOND C (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:415 RIVA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8652
Mailing Address - Country:US
Mailing Address - Phone:859-624-0355
Mailing Address - Fax:707-924-0355
Practice Address - Street 1:PATTIE A CLAY REGIONAL MEDICAL CENTER
Practice Address - Street 2:EASTERN BYPASS
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40476-2603
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY17436207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC73997Medicare UPIN