Provider Demographics
NPI:1912165234
Name:JACKSON, JAMES BENJAMIN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BENJAMIN
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22265
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4473
Mailing Address - Country:US
Mailing Address - Phone:803-296-7846
Mailing Address - Fax:803-296-9699
Practice Address - Street 1:2 MEDICAL PARK RD
Practice Address - Street 2:LOWER LEVEL SUITE L9/L10
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6808
Practice Address - Country:US
Practice Address - Phone:803-434-6812
Practice Address - Fax:803-434-7306
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37261207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC372616Medicaid
SCSC41342488Medicare PIN