Provider Demographics
NPI:1952152845
Name:JACKSON, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:110 S PACA ST
Mailing Address - Street 2:6TH FLOOR, SUITE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201
Mailing Address - Country:US
Mailing Address - Phone:667-214-2208
Mailing Address - Fax:
Practice Address - Street 1:110 S PACA ST
Practice Address - Street 2:6TH FLOOR, SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:667-214-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program