Provider Demographics
NPI:1619064573
Name:R. BRUCE JACKSON II, M.D., P.A.
Entity Type:Organization
Organization Name:R. BRUCE JACKSON II, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:828-262-9696
Mailing Address - Street 1:222 LONGVUE DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5060
Mailing Address - Country:US
Mailing Address - Phone:828-262-9696
Mailing Address - Fax:828-265-2306
Practice Address - Street 1:222 LONGVUE DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5060
Practice Address - Country:US
Practice Address - Phone:828-262-9696
Practice Address - Fax:828-265-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24975207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB05345Medicare UPIN