Provider Demographics
NPI:1538114749
Name:JACKSON, GEORGE WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
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 1:2200 WEST MAIN STREET
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4677
Mailing Address - Country:US
Mailing Address - Phone:919-286-3232
Mailing Address - Fax:
Practice Address - Street 1:2200 WEST MAIN STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4677
Practice Address - Country:US
Practice Address - Phone:919-286-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC262722083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC230575Medicare PIN
NCC87689Medicare UPIN