Provider Demographics
NPI:1619161858
Name:JACKSON, KURT T (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:T
Last Name:JACKSON
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 1:22 OLD SHORT HILLS RD STE 202104
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5604
Mailing Address - Country:US
Mailing Address - Phone:201-961-3975
Mailing Address - Fax:973-707-7349
Practice Address - Street 1:22 OLD SHORT HILLS RD STE 202
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5605
Practice Address - Country:US
Practice Address - Phone:201-961-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09011700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ371351Medicaid