Provider Demographics
NPI:1114708260
Name:JACKSON MEDIA INC
Entity Type:Organization
Organization Name:JACKSON MEDIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-604-4793
Mailing Address - Street 1:4210 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5087
Mailing Address - Country:US
Mailing Address - Phone:209-432-5576
Mailing Address - Fax:
Practice Address - Street 1:4210 27TH ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5087
Practice Address - Country:US
Practice Address - Phone:209-432-5576
Practice Address - Fax:209-432-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies