Provider Demographics
NPI:1689737074
Name:JACKSON, ERIC MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MICHAEL
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 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:410-955-0626
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:PHIPPS 571
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-7171
Practice Address - Fax:410-955-0626
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076696207T00000X
OH35095700207T00000X
MA239160207T00000X
PAMD424942207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJA4296251Medicare PIN