Provider Demographics
NPI:1952386690
Name:JACKSON, RICHARD ALLEN (HS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 PEETS ST
Mailing Address - Street 2:
Mailing Address - City:OTIS ANGB
Mailing Address - State:MA
Mailing Address - Zip Code:02542-1030
Mailing Address - Country:US
Mailing Address - Phone:503-504-6492
Mailing Address - Fax:
Practice Address - Street 1:KAEHLER MEMORIAL MEDICAL CLINIC
Practice Address - Street 2:US COAST GUARD
Practice Address - City:OTIS ANGB
Practice Address - State:MA
Practice Address - Zip Code:02542
Practice Address - Country:US
Practice Address - Phone:508-968-6713
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB0415118146N00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Not Answered247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other