Provider Demographics
NPI:1750120804
Name:JACKSON, CHRISTOPHER P (MA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05601-0647
Mailing Address - Country:US
Mailing Address - Phone:802-479-4055
Mailing Address - Fax:802-661-5699
Practice Address - Street 1:23 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-3741
Practice Address - Country:US
Practice Address - Phone:802-479-4055
Practice Address - Fax:802-661-5699
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker