Healthcare Provider Details

I. General information

NPI: 1912313461
Provider Name (Legal Business Name): MR. JEREMY SCOTT JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2014
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST DEPARTMENT OF ANESTHESIA
BOSTON MA
02114-2621
US

IV. Provider business mailing address

NWH ANESTHESIOLOGY 2014 WASHINGTON STREET
NEWTON MA
02462
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone: 617-243-6298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2292777
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: