Provider Demographics
NPI:1982811709
Name:JACKSON, JANE E (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:E
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 1:3513 SANDY CT
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1420
Mailing Address - Country:US
Mailing Address - Phone:301-466-2562
Mailing Address - Fax:301-949-9666
Practice Address - Street 1:3512 SANDY CT
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1420
Practice Address - Country:US
Practice Address - Phone:301-466-2562
Practice Address - Fax:301-949-9666
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028973103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMSI MAPSIOther385639
DCK1240001OtherCAREFIRST BCBS
MD343BJEOtherCAREFIRST BCBS
MAMSI MAPSIOther385639