Healthcare Provider Details

I. General information

NPI: 1780611590
Provider Name (Legal Business Name): JEFFREY BURKE JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SENECA RD
ELKINS WV
26241-9709
US

IV. Provider business mailing address

125 N 6TH ST
CLARKSBURG WV
26301-2665
US

V. Phone/Fax

Practice location:
  • Phone: 304-637-2777
  • Fax: 304-636-8825
Mailing address:
  • Phone: 304-624-7200
  • Fax: 304-636-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number16375
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number16375
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: