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General NPI Number Information
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NPI Number | 1891796900
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Entity Type | Individual
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Provider Name | DAVID SPENCER JACKSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/10/2005
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Last Update Date | 08/22/2019
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Provider Practice Location Address
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Address Line | 11055 LITTLE PATUXENT PKWY SUITE 205
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City | COLUMBIA
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State | MD
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Zip | 21044-2896
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Country | US
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Telephone | 410-740-0789
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Fax | 410-740-7024
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Provider Business Mailing Address
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Address Line | 7580 BUCKINGHAM BLVD STE 220
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City | HANOVER
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State | MD
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Zip | 21076-3210
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Country | US
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Telephone | 410-729-5100
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Fax |
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | D35217
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License Number State | MD
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