Provider Demographics
NPI:1457961559
Name:RICHARD T JACKSON LLC
Entity Type:Organization
Organization Name:RICHARD T JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-957-7648
Mailing Address - Street 1:7 SOUTHSIDE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3894
Mailing Address - Country:US
Mailing Address - Phone:518-709-0005
Mailing Address - Fax:
Practice Address - Street 1:3 LEAR JET LN STE 203
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2322
Practice Address - Country:US
Practice Address - Phone:518-258-4033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD T JACKSON LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty