Healthcare Provider Details

I. General information

NPI: 1629502562
Provider Name (Legal Business Name): BENJAMIN POPP JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 N KANAWHA ST
BUCKHANNON WV
26201-2714
US

IV. Provider business mailing address

34 N KANAWHA ST
BUCKHANNON WV
26201-2714
US

V. Phone/Fax

Practice location:
  • Phone: 304-473-2250
  • Fax: 304-472-1208
Mailing address:
  • Phone: 304-473-2250
  • Fax: 304-472-1208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number30171
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: