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NPI Code Detail

MEDICARE: RICHARD T JACKSON LLC

MEDICARE: RICHARD T JACKSON LLC
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
12084N0400XNeurology Physician

General Provider Information

NPI Number : 1457961559
Entity Type Code : Organization
Provider Name (Legal Business Name) : RICHARD T JACKSON LLC
Provider Business Mailing Address
First Line : 7 SOUTHSIDE DR STE 206
Second Line :
City : CLIFTON PARK
State : NY
Zip : 12065-3894
Country : US
Telephone Number : 518-709-0005
Fax Number :
Provider Business Practice Location Address
First Line : 3 LEAR JET LN STE 203
Second Line :
City : LATHAM
State : NY
Zip : 12110-2322
Country : US
Telephone Number : 518-258-4033
Fax Number :
Authorized Official
Title or Position : OWNER
Name : RICHARD T JACKSON
Credential : MD
Telephone Number : 646-957-7648
Provider Enumeration Date : 08/04/2020
Last Update Date : 08/04/2020

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