Provider Demographics
NPI:1366483406
Name:JACKSON, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
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 1:29 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RONKS
Mailing Address - State:PA
Mailing Address - Zip Code:17572-9769
Mailing Address - Country:US
Mailing Address - Phone:717-299-5711
Mailing Address - Fax:
Practice Address - Street 1:29 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:RONKS
Practice Address - State:PA
Practice Address - Zip Code:17572-9769
Practice Address - Country:US
Practice Address - Phone:717-299-5711
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031678E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1160742Medicaid
PA1160742Medicaid
PAB67991Medicare UPIN