Provider Demographics
NPI:1568409852
Name:JACKSON, PAUL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
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 1:272 HOSPITAL RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-8234
Mailing Address - Fax:740-779-7477
Practice Address - Street 1:272 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9031
Practice Address - Country:US
Practice Address - Phone:740-779-8575
Practice Address - Fax:740-779-8579
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY207R00000X
OH35.086453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2813432Medicaid
TX144066Medicare UPIN
OH2813432Medicaid