=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821141219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM G JACKSON, M.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 03/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 TOLL RD UNIT B
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01952-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-462-3009
-----------------------------------------------------
Fax | 978-462-0177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 TOLL RD UNIT B
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01952-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-462-3009
-----------------------------------------------------
Fax | 978-462-0177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM G. JACKSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 978-462-3009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 57551
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------