Provider Demographics
NPI:1417168667
Name:JACKSON, ALBERT JEROME JR (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:JEROME
Last Name:JACKSON
Suffix:JR
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 1:2710 SAINT FRANCIS DR
Mailing Address - Street 2:STE 410
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5619
Mailing Address - Country:US
Mailing Address - Phone:319-272-5000
Mailing Address - Fax:
Practice Address - Street 1:2710 SAINT FRANCIS DR
Practice Address - Street 2:STE 410
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5619
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37967207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP2-0023863OtherINSTITUTIONAL PERMIT