Provider Demographics
NPI:1811041197
Name:JACKSON, DARRYL BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:BRETT
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 1:5801 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3833
Mailing Address - Country:US
Mailing Address - Phone:610-755-2594
Mailing Address - Fax:
Practice Address - Street 1:5801 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3833
Practice Address - Country:US
Practice Address - Phone:610-755-2594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044865L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012855500001Medicaid
PA00128550001Medicaid
PAJA703237Medicare ID - Type Unspecified
PA00128550001Medicaid