Provider Demographics
NPI:1962472407
Name:JACKSON, DOUGLAS T (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18925
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07191
Mailing Address - Country:US
Mailing Address - Phone:973-972-3555
Mailing Address - Fax:973-972-3510
Practice Address - Street 1:150 BARGEN ST
Practice Address - Street 2:F 102
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-3555
Practice Address - Fax:973-972-3510
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06601400207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6716407Medicaid
NJ6716407Medicaid
NJ003800Medicare ID - Type Unspecified