Healthcare Provider Details

I. General information

NPI: 1003843590
Provider Name (Legal Business Name): WILLIAM GROVER JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 TOLL RD UNIT B
SALISBURY MA
01952-1435
US

IV. Provider business mailing address

46 TOLL RD UNIT B
SALISBURY MA
01952-1435
US

V. Phone/Fax

Practice location:
  • Phone: 978-462-3009
  • Fax: 978-462-0177
Mailing address:
  • Phone: 978-462-3009
  • Fax: 978-462-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57551
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number57551
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: