Provider Demographics
NPI:1922132281
Name:R. KIRK JACKSON, M.D., P.A.
Entity Type:Organization
Organization Name:R. KIRK JACKSON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KIRK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-698-2440
Mailing Address - Street 1:82 THOMAS JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-698-2440
Mailing Address - Fax:301-846-0892
Practice Address - Street 1:82 THOMAS JOHNSON CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4348
Practice Address - Country:US
Practice Address - Phone:301-698-2440
Practice Address - Fax:301-846-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0039847174400000X
MDD0059947174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE59093Medicare UPIN
MDH28757Medicare UPIN