Provider Demographics
NPI:1417078908
Name:JACKSON, ALFRED B III (PA-C, MBA)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:B
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:PA-C, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 SLATE HILL DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19363-1833
Mailing Address - Country:US
Mailing Address - Phone:610-932-7007
Mailing Address - Fax:
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:SUITE 4154
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-428-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000216363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical