Provider Demographics
NPI:1386974491
Name:JACKSON MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:JACKSON MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:RN
Authorized Official - Phone:707-446-7014
Mailing Address - Street 1:506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3922
Mailing Address - Country:US
Mailing Address - Phone:707-446-7014
Mailing Address - Fax:707-446-1871
Practice Address - Street 1:506 MAIN ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3922
Practice Address - Country:US
Practice Address - Phone:707-446-7014
Practice Address - Fax:707-446-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103834332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03183FMedicaid
CA03183FMedicaid