Healthcare Provider Details

I. General information

NPI: 1164442406
Provider Name (Legal Business Name): ROBERT KIRK JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

IV. Provider business mailing address

82 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

V. Phone/Fax

Practice location:
  • Phone: 301-698-2440
  • Fax: 301-846-0892
Mailing address:
  • Phone: 301-698-2440
  • Fax: 301-846-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0039847
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: