Provider Demographics
NPI:1821181991
Name:JACKSON, LINDA CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:CAROL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-4701
Mailing Address - Fax:304-329-4716
Practice Address - Street 1:150 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:770-778-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040928174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00697606BMedicaid
GA6593349OtherCIGNA
GA20BBFTQMedicare PIN
GAF47674Medicare UPIN