MEDICARE: DR. TIMOTHY K JACKSON M. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	13532	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255444766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY K JACKSON M. D.

Provider Business Mailing Address
First Line	:	PO BOX 763
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0763
Country	:	US
Telephone Number	:	800-541-4009
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 GENESIS BLVD
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-9668
Country	:	US
Telephone Number	:	681-342-3070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	04/06/2022

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