Provider Demographics
NPI:1891275137
Name:JACKSON, JAMAL D
Entity Type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6206 CHEVERLY PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3050
Mailing Address - Country:US
Mailing Address - Phone:301-789-8810
Mailing Address - Fax:
Practice Address - Street 1:4175 N HANSON CT STE 301
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3186
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist