Healthcare Provider Details

I. General information

NPI: 1801813407
Provider Name (Legal Business Name): PAMELA DAWN RANDOLPH JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010
US

IV. Provider business mailing address

12605 WILLOW MARSH LANE
BOWIE MD
20720
US

V. Phone/Fax

Practice location:
  • Phone: 800-353-0788
  • Fax: 804-355-6031
Mailing address:
  • Phone: 301-262-1528
  • Fax: 804-355-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberDC 19357
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: