1023319985 NPI number — MR. MARTIN JACKSON SR. MED., LADC

Table of content: MR. MARTIN JACKSON SR. MED., LADC (NPI 1023319985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023319985 NPI number — MR. MARTIN JACKSON SR. MED., LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARTIN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
MED., LADC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023319985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 467
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-0467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-559-5759
Provider Business Mailing Address Fax Number:
860-559-5759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 BARNARD LN
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06002-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-559-5759
Provider Business Practice Location Address Fax Number:
860-559-5759
Provider Enumeration Date:
11/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  000158 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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