Provider Demographics
NPI:1124019369
Name:JACKSON, WILLIAM A (RPA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-2209
Practice Address - Street 1:33 MITCHELL AVE
Practice Address - Street 2:SUITE G50
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1619
Practice Address - Country:US
Practice Address - Phone:607-771-2220
Practice Address - Fax:607-771-2225
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02407216Medicaid
NYBB9926Medicare PIN
P03354Medicare UPIN