Healthcare Provider Details

I. General information

NPI: 1528421955
Provider Name (Legal Business Name): MICHAEL JAMES JACKSON RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 04/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 CURTIS DR
WINDHAM ME
04062-4704
US

IV. Provider business mailing address

19 CURTIS DR
WINDHAM ME
04062-4704
US

V. Phone/Fax

Practice location:
  • Phone: 207-318-4072
  • Fax:
Mailing address:
  • Phone: 207-318-4072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR048931
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: