Provider Demographics
NPI:1912313461
Name:JACKSON, JEREMY SCOTT
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NWH ANESTHESIOLOGY
Mailing Address - Street 2:2014 WASHINGTON STREET
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462
Mailing Address - Country:US
Mailing Address - Phone:617-243-6298
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-05
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2292777367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered