Provider Demographics
NPI:1407127640
Name:DR RICHARD K JACKSON PA
Entity Type:Organization
Organization Name:DR RICHARD K JACKSON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-737-6445
Mailing Address - Street 1:326 W BOYNTON BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-4025
Mailing Address - Country:US
Mailing Address - Phone:561-737-6445
Mailing Address - Fax:561-737-1524
Practice Address - Street 1:326 W BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-4025
Practice Address - Country:US
Practice Address - Phone:561-737-6445
Practice Address - Fax:561-737-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073772100Medicaid