Provider Demographics
NPI:1427600378
Name:JACKSON, CHARLES MITCHELL (BS, TSS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MITCHELL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BS, TSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W 22ND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-4086
Mailing Address - Country:US
Mailing Address - Phone:267-628-9156
Mailing Address - Fax:
Practice Address - Street 1:320 MACDADE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023-1926
Practice Address - Country:US
Practice Address - Phone:610-522-4506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center