Provider Demographics
NPI:1790786101
Name:JACKSON, YVONNE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14300 GALLANT FOX LN
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4003
Mailing Address - Country:US
Mailing Address - Phone:301-262-4784
Mailing Address - Fax:301-262-2767
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 203
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-262-4784
Practice Address - Fax:301-262-2767
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD50706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics