Healthcare Provider Details

I. General information

NPI: 1235355173
Provider Name (Legal Business Name): CARL-CHRISTIAN ANDREW JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 190
PROVIDENCE RI
02905-3248
US

IV. Provider business mailing address

15 LASALLE SQUARE
PROVIDENCE RI
02903
US

V. Phone/Fax

Practice location:
  • Phone: 401-228-0623
  • Fax: 401-868-2319
Mailing address:
  • Phone: 401-444-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA88272
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberMD18790
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number231415
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-106668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: