Provider Demographics
NPI:1184719023
Name:JACKSON, JEANETTE HELEN (DO)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:HELEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:RICHWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26261-1236
Mailing Address - Country:US
Mailing Address - Phone:304-846-2573
Mailing Address - Fax:304-846-6389
Practice Address - Street 1:75 AVENUE B
Practice Address - Street 2:
Practice Address - City:RICHWOOD
Practice Address - State:WV
Practice Address - Zip Code:26261-1236
Practice Address - Country:US
Practice Address - Phone:304-846-2573
Practice Address - Fax:304-846-6389
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1780207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6000951000Medicaid
WVH10310Medicare UPIN