Provider Demographics
NPI:1891848529
Name:JACKSON, JAMES FRED (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:FRED
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2700
Mailing Address - Country:US
Mailing Address - Phone:304-599-1602
Mailing Address - Fax:304-225-6604
Practice Address - Street 1:1193 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2700
Practice Address - Country:US
Practice Address - Phone:304-599-1602
Practice Address - Fax:304-225-6604
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice