Provider Demographics
NPI:1932427218
Name:JACKSON, RICHARD THOMAS CLEARY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS CLEARY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:102 PARK ST
Practice Address - Street 2:GLENS FALLS HOSPITAL NEUROLOGY
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4403
Practice Address - Country:US
Practice Address - Phone:518-926-2940
Practice Address - Fax:518-926-2941
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS271162084N0400X
NY2669312084N0400X
ARE-125082084N0400X
TN529782084N0400X
NC2021-032052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03767571Medicaid