Provider Demographics
NPI:1780825224
Name:JACKSON FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAINTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO,MPA,MT,ASCP
Authorized Official - Phone:301-885-3350
Mailing Address - Street 1:PO BOX 7876
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-7876
Mailing Address - Country:US
Mailing Address - Phone:301-885-3350
Mailing Address - Fax:301-885-0061
Practice Address - Street 1:10 SAINT PATRICKS DR
Practice Address - Street 2:#502
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4527
Practice Address - Country:US
Practice Address - Phone:301-885-3350
Practice Address - Fax:301-885-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0058218261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care