Provider Demographics
NPI:1548203482
Name:JACKSON, PRUDENCE (MD)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
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 1:10515 BILL LILLY CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1291
Mailing Address - Country:US
Mailing Address - Phone:301-953-2747
Mailing Address - Fax:
Practice Address - Street 1:900 CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD37659207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD60609101OtherBLUE CROSS
MDP00213513OtherRAILROAD MEDICARE
MD180MJ824Medicare ID - Type Unspecified
MD60609101OtherBLUE CROSS