Provider Demographics
NPI:1407947039
Name:JACKSON, DONALD J (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:185 GRAFTON RD.
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-0216
Mailing Address - Country:US
Mailing Address - Phone:802-365-4331
Mailing Address - Fax:802-365-7031
Practice Address - Street 1:185 GRAFTON RD.
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353
Practice Address - Country:US
Practice Address - Phone:802-365-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOAP1167Medicaid
VTOAP1167Medicaid
473981Medicare Oscar/Certification
VN0834Medicare Oscar/Certification
AP1167Medicare PIN