Provider Demographics
NPI:1235355173
Name:JACKSON, CARL-CHRISTIAN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:CARL-CHRISTIAN
Middle Name:ANDREW
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 1:15 LASALLE SQUARE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-444-3239
Mailing Address - Fax:
Practice Address - Street 1:2 DUDLEY ST STE 190
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3248
Practice Address - Country:US
Practice Address - Phone:401-228-0623
Practice Address - Fax:401-868-2319
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88272208G00000X
RIMD187902086S0120X
MA2314152086S0120X
IL036-106668208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A882720Medicaid
CA00A882720Medicaid