Provider Demographics
NPI:1760412076
Name:JACKSON, T. SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:T.
Middle Name:SCOTT
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 1:4131 OREGON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-9550
Mailing Address - Country:US
Mailing Address - Phone:717-859-5161
Mailing Address - Fax:717-859-5169
Practice Address - Street 1:4131 OREGON PIKE
Practice Address - Street 2:
Practice Address - City:BROWNSTON
Practice Address - State:PA
Practice Address - Zip Code:17508
Practice Address - Country:US
Practice Address - Phone:717-859-1123
Practice Address - Fax:717-859-2898
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029835E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010105110006Medicaid
PA50051189OtherCAPITAL BLUE
PAP002396OtherGATEWAY
PA117553OtherBLUE SHIELD
PA50051189OtherCAPITAL BLUE
C30601Medicare UPIN