Provider Demographics
NPI:1770707093
Name:JACKSON, EVELYN DIANE (MD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:DIANE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3416 OLANDWOOD CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1372
Mailing Address - Country:US
Mailing Address - Phone:301-774-5600
Mailing Address - Fax:
Practice Address - Street 1:3416 OLANDWOOD CT
Practice Address - Street 2:SUITE 200
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1372
Practice Address - Country:US
Practice Address - Phone:301-774-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD25560-1002Medicaid
D74643Medicare UPIN
MD25560-1002Medicaid