Healthcare Provider Details

I. General information

NPI: 1790765667
Provider Name (Legal Business Name): THOMAS R JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 STATE ST
SCHENECTADY NY
12305-2414
US

IV. Provider business mailing address

121 EVERETT RD
ALBANY NY
12205-1474
US

V. Phone/Fax

Practice location:
  • Phone: 518-489-2663
  • Fax:
Mailing address:
  • Phone: 518-489-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMT179687
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD13171
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2011-00970
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD13171
License Number StateRI
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number246110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: