Provider Demographics
NPI:1609847631
Name:JACKSON, JOSEPH ALEXANDER IV (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ALEXANDER
Last Name:JACKSON
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:A
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:STATION LANDING/CCAD
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:781-306-8655
Mailing Address - Fax:781-306-8655
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:STATION LANDING/CCAD
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:781-306-8655
Practice Address - Fax:781-306-8655
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2173742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ26769OtherBCBS PROVIDER
MA2020203Medicaid
MA2020203Medicaid