Provider Demographics
NPI:1568644185
Name:JACKSON, VICTOR (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-8161
Mailing Address - Country:US
Mailing Address - Phone:814-274-9300
Mailing Address - Fax:
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA148847JT3Medicare PIN