Provider Demographics
NPI:1477314656
Name:JACKSON, THOMAS JEFFERSON III
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JEFFERSON
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9604 STUART LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3376
Mailing Address - Country:US
Mailing Address - Phone:240-547-7904
Mailing Address - Fax:
Practice Address - Street 1:9604 STUART LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3376
Practice Address - Country:US
Practice Address - Phone:240-547-7904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator