Provider Demographics
NPI:1023718731
Name:JACKSON, JOHN H JR
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:H
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 HAWKINS ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-4318
Mailing Address - Country:US
Mailing Address - Phone:862-272-9354
Mailing Address - Fax:
Practice Address - Street 1:66 HAWKINS ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-4318
Practice Address - Country:US
Practice Address - Phone:862-272-9354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJJ0062-40768-06852172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver