MEDICARE: JULIAN ALEXANDER JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		PA

General Provider Information

NPI Number	:	1164352647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIAN ALEXANDER JACKSON

Provider Business Mailing Address
First Line	:	111 S 11TH ST STE 8290
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4870
Country	:	US
Telephone Number	:	443-996-0748
Fax Number	:

Provider Business Practice Location Address
First Line	:	132 S 10TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5244
Country	:	US
Telephone Number	:	215-955-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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