Healthcare Provider Details

I. General information

NPI: 1790786101
Provider Name (Legal Business Name): YVONNE MARIE JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 GALLANT FOX LN SUITE 203
BOWIE MD
20715-4003
US

IV. Provider business mailing address

14300 GALLANT FOX LN SUITE 203
BOWIE MD
20715-4003
US

V. Phone/Fax

Practice location:
  • Phone: 301-262-4784
  • Fax: 301-262-2767
Mailing address:
  • Phone: 301-262-4784
  • Fax: 301-262-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD50706
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: