Provider Demographics
NPI:1922244060
Name:JACKSON FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-683-0010
Mailing Address - Street 1:80 SCENIC DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5210
Mailing Address - Country:US
Mailing Address - Phone:732-683-0010
Mailing Address - Fax:
Practice Address - Street 1:80 SCENIC DR
Practice Address - Street 2:SUITE 6
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-5210
Practice Address - Country:US
Practice Address - Phone:732-683-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05981900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTIN