Healthcare Provider Details

I. General information

NPI: 1952386690
Provider Name (Legal Business Name): RICHARD ALLEN JACKSON HS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KAEHLER MEMORIAL MEDICAL CLINIC US COAST GUARD
OTIS ANGB MA
02542
US

IV. Provider business mailing address

5690 PEETS ST
OTIS ANGB MA
02542-1030
US

V. Phone/Fax

Practice location:
  • Phone: 508-968-6713
  • Fax:
Mailing address:
  • Phone: 503-504-6492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB0415118
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: