=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235355173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL-CHRISTIAN ANDREW JACKSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 DUDLEY ST STE 190
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02905-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-228-0623
-----------------------------------------------------
Fax | 401-868-2319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 LASALLE SQUARE
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-444-3239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | A88272
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0120X
-----------------------------------------------------
Taxonomy Name | Pediatric Surgery Physician
-----------------------------------------------------
License Number | MD18790
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2086S0120X
-----------------------------------------------------
Taxonomy Name | Pediatric Surgery Physician
-----------------------------------------------------
License Number | 231415
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036-106668
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------