Provider Demographics
NPI:1215471743
Name:ERIC JACKSON MD, LLC
Entity type:Organization
Organization Name:ERIC JACKSON MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-997-1010
Mailing Address - Street 1:16 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031
Mailing Address - Country:US
Mailing Address - Phone:201-997-1010
Mailing Address - Fax:201-997-7436
Practice Address - Street 1:16 RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6339
Practice Address - Country:US
Practice Address - Phone:201-997-1010
Practice Address - Fax:201-997-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD20034Medicare UPIN