Provider Demographics
NPI:1184060188
Name:JACKSON, RYAN CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:CHRISTOPHER
Last Name:JACKSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2363
Mailing Address - Country:US
Mailing Address - Phone:207-662-0111
Mailing Address - Fax:207-662-8133
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2363
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:207-662-8133
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD20548207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400334169Medicare PIN