MEDICARE: LON JACKMAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1255608170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LON JACKMAN

Provider Business Mailing Address
First Line	:	200 ROUTE 108
Second Line	:
City	:	SOMERSWORTH
State	:	NH
Zip	:	03878-1119
Country	:	US
Telephone Number	:	603-953-0077
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 ROUTE 108
Second Line	:
City	:	SOMERSWORTH
State	:	NH
Zip	:	03878-1119
Country	:	US
Telephone Number	:	603-953-0077
Fax Number	:

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

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	11/21/2011

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Directions to “ LON JACKMAN ” Practice Location

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