Healthcare Provider Details

I. General information

NPI: 1376479626
Provider Name (Legal Business Name): LUKE S JACKSON CRITICAL CARE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7027
US

IV. Provider business mailing address

189 ODLIN RD
BANGOR ME
04401-6703
US

V. Phone/Fax

Practice location:
  • Phone: 207-275-2961
  • Fax:
Mailing address:
  • Phone: 207-275-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number30299
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License NumberRN79258
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: