Provider Demographics
NPI:1235355173
Name:JACKSON, CARL-CHRISTIAN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:CARL-CHRISTIAN
Middle Name:ANDREW
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WASHINGTON ST
Mailing Address - Street 2:TUFTS-NEMC #344
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1526
Mailing Address - Country:US
Mailing Address - Phone:617-636-5025
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:TUFTS-NEMC #344
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106668208600000X
CAA88272208G00000X
MA2314152086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A882720Medicaid
CA00A882720Medicaid