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General NPI Number Information
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NPI Number | 1780825224
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Entity Type | Organization
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Legal Business Name | JACKSON FAMILY MEDICINE, LLC
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Dates
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Enumeration Date | 03/12/2009
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Last Update Date | 03/12/2009
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Provider Practice Location Address
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Address Line | 10 SAINT PATRICKS DR #502
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City | WALDORF
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State | MD
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Zip | 20603-4527
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Country | US
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Telephone | 301-885-3350
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Fax | 301-885-0061
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Provider Business Mailing Address
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Address Line | PO BOX 7876
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City | UPPER MARLBORO
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State | MD
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Zip | 20792-7876
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Country | US
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Telephone | 301-885-3350
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Fax | 301-885-0061
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. DAINTY J JACKSON
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Credential | DO.,MPA.,MT.,ASCP.
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Telephone | 301-885-3350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | H0058218
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License Number State | MD
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