Provider Demographics
NPI:1497136600
Name:JACKSON, KAVITA SRIVASTAVA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:SRIVASTAVA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FOREST GLEN RD
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1484
Mailing Address - Country:US
Mailing Address - Phone:301-754-7000
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD DEPT OF
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1460
Practice Address - Country:US
Practice Address - Phone:301-754-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209033390200000X
MDD0086968207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program