Healthcare Provider Details

I. General information

NPI: 1790085660
Provider Name (Legal Business Name): DR. JACKSON CARNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15411 NEW HAMPSHIRE AVE
SILVER SPRING MD
20905-4162
US

IV. Provider business mailing address

3642 GLENEAGLES DR #1H
SILVER SPRING MD
20906-1631
US

V. Phone/Fax

Practice location:
  • Phone: 301-476-8303
  • Fax:
Mailing address:
  • Phone: 301-598-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6631
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: