Healthcare Provider Details

I. General information

NPI: 1891796900
Provider Name (Legal Business Name): DAVID SPENCER JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11055 LITTLE PATUXENT PKWY SUITE 205
COLUMBIA MD
21044-2896
US

IV. Provider business mailing address

7580 BUCKINGHAM BLVD STE 220
HANOVER MD
21076-3210
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-0789
  • Fax: 410-740-7024
Mailing address:
  • Phone: 410-729-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD35217
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: