Provider Demographics
NPI:1619905072
Name:JACKSON, PAMELA LEE (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HARBOR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7849
Mailing Address - Country:US
Mailing Address - Phone:802-863-8962
Mailing Address - Fax:
Practice Address - Street 1:353 BLAIR PARK RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7530
Practice Address - Country:US
Practice Address - Phone:802-847-1440
Practice Address - Fax:802-847-3014
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0008559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0393Medicaid
NYE01148865Medicaid
NYE01148865Medicaid