Provider Demographics
NPI:1104931062
Name:JACKSON, HELEN T (MD)
Entity type:Individual
Prefix:
First Name:HELEN
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 BEACON ST
Mailing Address - Street 2:SUITE 5D
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3885
Mailing Address - Country:US
Mailing Address - Phone:617-277-7583
Mailing Address - Fax:617-277-5598
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 5D
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-277-7583
Practice Address - Fax:617-277-5598
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME36280OtherLICENSE #
MA2061376Medicaid
ME36280OtherLICENSE #
D08851Medicare UPIN