Provider Demographics
NPI:1245330950
Name:JACKSON, THOMAS E (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
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 1:47 MAPLE ST #205
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:908-522-9400
Mailing Address - Fax:908-522-3226
Practice Address - Street 1:47 MAPLE ST #205
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901
Practice Address - Country:US
Practice Address - Phone:908-522-9400
Practice Address - Fax:908-522-3226
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA48570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UP138OtherOXFORD
11383OtherAETNA
A29206Medicare UPIN
441066Medicare ID - Type Unspecified