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General NPI Number Information
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NPI Number | 1184060188
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Entity Type | Individual
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Provider Name | RYAN CHRISTOPHER JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 05/16/2013
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Last Update Date | 03/13/2025
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Provider Practice Location Address
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Address Line | 335 BRIGHTON AVE
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City | PORTLAND
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State | ME
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Zip | 04102-2363
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Country | US
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Telephone | 207-662-0111
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Fax | 207-662-8133
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Provider Business Mailing Address
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Address Line | 335 BRIGHTON AVE
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City | PORTLAND
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State | ME
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Zip | 04102-2363
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Country | US
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Telephone | 207-662-0111
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Fax | 207-662-8133
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | MD20548
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License Number State | ME
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