Provider Demographics
NPI:1962602458
Name:F. DANIEL JACKSON, MD, PA
Entity type:Organization
Organization Name:F. DANIEL JACKSON, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:F.
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:301-759-3410
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1692
Mailing Address - Country:US
Mailing Address - Phone:301-759-3817
Mailing Address - Fax:301-759-3043
Practice Address - Street 1:715 WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-759-3410
Practice Address - Fax:301-759-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 261QR0200X
MDD0020433261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD440082800Medicaid
MD305591400Medicaid
MD305591400Medicaid
MD433LMedicare PIN