Provider Demographics
NPI:1396838868
Name:JACKSON, ANTHONY HAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:HAIG
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 1:31 WOODLAWN AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492
Mailing Address - Country:US
Mailing Address - Phone:508-977-3481
Mailing Address - Fax:781-449-2787
Practice Address - Street 1:31 WOODLAWN AVENUE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:508-977-3481
Practice Address - Fax:781-449-2787
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA345672084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB33592Medicare ID - Type Unspecified
MAB73027Medicare UPIN