Provider Demographics
NPI:1629502562
Name:JACKSON, BENJAMIN POPP (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:POPP
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:34 N KANAWHA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2714
Mailing Address - Country:US
Mailing Address - Phone:304-473-2250
Mailing Address - Fax:304-472-1208
Practice Address - Street 1:34 N KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2714
Practice Address - Country:US
Practice Address - Phone:304-473-2250
Practice Address - Fax:304-472-1208
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30171207QA0401X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine