Provider Demographics
NPI:1750548657
Name:BERNICE D JACKSON MD CARDIOLOGY SERVICES, PLLC
Entity type:Organization
Organization Name:BERNICE D JACKSON MD CARDIOLOGY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-269-9249
Mailing Address - Street 1:1160 VARNUM ST NE
Mailing Address - Street 2:SUITE 314
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2107
Mailing Address - Country:US
Mailing Address - Phone:202-269-9249
Mailing Address - Fax:202-269-9271
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-269-9249
Practice Address - Fax:202-269-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD17118207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027063100Medicaid
DC1639195407OtherNPI INDIVIDUAL
DC027063100Medicaid