Healthcare Provider Details

I. General information

NPI: 1881040277
Provider Name (Legal Business Name): CHRISTOPHER EZEKIEL JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 E MONUMENT ST
BALTIMORE MD
21205-2431
US

IV. Provider business mailing address

2800 EISENHOWER AVE STE 220
ALEXANDRIA VA
22314-4587
US

V. Phone/Fax

Practice location:
  • Phone: 667-207-3552
  • Fax: 443-885-9778
Mailing address:
  • Phone: 301-246-2586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101271955
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25IA12466800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number50004
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD210003060
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0094354
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: