Provider Demographics
NPI:1609205483
Name:THE JACKSON LABORATORY
Entity Type:Organization
Organization Name:THE JACKSON LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR, CLINIC GENOMICS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-837-2131
Mailing Address - Street 1:610 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1526
Mailing Address - Country:US
Mailing Address - Phone:207-288-6000
Mailing Address - Fax:
Practice Address - Street 1:10 DISCOVERY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2374
Practice Address - Country:US
Practice Address - Phone:860-837-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCL-0695291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory