Provider Demographics
NPI:1619934502
Name:JACKSON, REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:834 CHESTNUT ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:834 CHESTNUT ST
Practice Address - Street 2:SUITE 420
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5127
Practice Address - Country:US
Practice Address - Phone:215-955-6776
Practice Address - Fax:215-955-4020
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422220207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0004588Medicaid
PA001960192Medicaid
PA071964Medicare PIN
NJ0004588Medicaid