Provider Demographics
NPI:1306838321
Name:JACKSON, ALTHEA J (MD)
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1330 POWELL ST
Mailing Address - Street 2:SUITE 507
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-3353
Mailing Address - Country:US
Mailing Address - Phone:610-279-9003
Mailing Address - Fax:610-270-2654
Practice Address - Street 1:2510 E DUPONT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1600
Practice Address - Country:US
Practice Address - Phone:260-490-9883
Practice Address - Fax:260-490-0064
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01052580A207V00000X
PAMD040658E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE55802Medicare UPIN
INE55802Medicare UPIN