Provider Demographics
NPI:1104243278
Name:JACKSON, COLIN BENJAMIN
Entity type:Individual
Prefix:MR
First Name:COLIN
Middle Name:BENJAMIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E CONCORD ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2335
Mailing Address - Country:US
Mailing Address - Phone:617-414-5166
Mailing Address - Fax:617-414-7300
Practice Address - Street 1:85 E CONCORD ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2335
Practice Address - Country:US
Practice Address - Phone:617-414-5166
Practice Address - Fax:617-414-7300
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA274359207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program