Provider Demographics
NPI:1104136126
Name:JACKSON MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:JACKSON MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIGMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-446-7014
Mailing Address - Street 1:604 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3405
Mailing Address - Country:US
Mailing Address - Phone:530-661-7409
Mailing Address - Fax:530-661-7345
Practice Address - Street 1:604 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3405
Practice Address - Country:US
Practice Address - Phone:530-661-7409
Practice Address - Fax:530-661-7345
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MEDICAL SUPPLY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53312332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies