Provider Demographics
NPI:1114999786
Name:JACKSON, REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 NEW ATHOL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:MA
Mailing Address - Zip Code:01364-9603
Mailing Address - Country:US
Mailing Address - Phone:978-544-7800
Mailing Address - Fax:978-544-0023
Practice Address - Street 1:119 NEW ATHOL RD STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:MA
Practice Address - Zip Code:01364-9603
Practice Address - Country:US
Practice Address - Phone:978-544-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208092207Q00000X, 207Q00000X
ME012825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083655AMedicaid
MAJ23829OtherBLUE CROSS BLUE SHIELD OF MA
MA47759OtherHEALTH NEW ENGLAND
MAAA159101OtherHARVARD PILGRIM HEALTHCARE
MA9611148OtherAETNA
MAMM3949Medicare PIN
MA47759OtherHEALTH NEW ENGLAND
MAMM3949Medicare PIN
MA47759OtherHEALTH NEW ENGLAND