Provider Demographics
NPI:1578873592
Name:JACKSON MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:JACKSON MEDICAL SUPPLY INC
Other - Org Name:JACKSON MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIGMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-446-7014
Mailing Address - Street 1:480 REDWOOD ST
Mailing Address - Street 2:# 44
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2958
Mailing Address - Country:US
Mailing Address - Phone:707-644-4170
Mailing Address - Fax:707-644-4163
Practice Address - Street 1:480 REDWOOD ST
Practice Address - Street 2:# 44
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2958
Practice Address - Country:US
Practice Address - Phone:707-644-4170
Practice Address - Fax:707-644-4163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MEDICAL SUPPLY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53238332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies