Healthcare Provider Details

I. General information

NPI: 1235131251
Provider Name (Legal Business Name): ERIC M JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16-18 RIDGE ROAD
NORTH RLINGTON NJ
07031-6314
US

IV. Provider business mailing address

16-18 RIDGE ROAD
NORTH ARLINGTON NJ
07031-6314
US

V. Phone/Fax

Practice location:
  • Phone: 201-997-1010
  • Fax: 201-997-7436
Mailing address:
  • Phone: 201-997-1010
  • Fax: 201-997-7436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA03676900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number25MA03676900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: