Provider Demographics
NPI:1417994179
Name:JACKSON, JOSEPH WELLINGTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WELLINGTON
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:PO BOX 5033
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36103-5033
Mailing Address - Country:US
Mailing Address - Phone:334-265-3140
Mailing Address - Fax:334-265-3150
Practice Address - Street 1:1501 FOREST AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1539
Practice Address - Country:US
Practice Address - Phone:334-265-3140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9002207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE78988Medicare UPIN