Provider Demographics
NPI:1598788101
Name:SMITH, JACKSON BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON BRUCE
Middle Name:
Last Name:SMITH
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 1:211 S 9TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 S 9TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6810
Practice Address - Country:US
Practice Address - Phone:215-955-8430
Practice Address - Fax:215-923-5828
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008957E207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1940805Medicaid
PA000793625Medicaid
NJ1940805Medicaid