Provider Demographics
NPI:1790782563
Name:JACKSON, FRANCIS D (MD, PA)
Entity Type:Individual
Prefix:
First Name:FRANCIS
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:F.
Other - Middle Name:DANIEL
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1692
Mailing Address - Country:US
Mailing Address - Phone:301-759-3817
Mailing Address - Fax:301-759-3286
Practice Address - Street 1:715 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6390
Practice Address - Country:US
Practice Address - Phone:301-759-3817
Practice Address - Fax:301-759-3286
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD204332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD305991400Medicaid
MD305991400Medicaid
MD433LMedicare ID - Type Unspecified