Provider Demographics
NPI:1912363458
Name:JACKSON, JASON (CPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-4129
Mailing Address - Country:US
Mailing Address - Phone:302-230-1271
Mailing Address - Fax:302-838-7034
Practice Address - Street 1:4 E WEALD AVE
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1664
Practice Address - Country:US
Practice Address - Phone:302-230-1271
Practice Address - Fax:302-838-7034
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE20160113145246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy