MEDICARE: DR. JEFFREY BURKE 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	207ND0900X	Dermatopathology Physician	16375	WV
2	207N00000X	Dermatology Physician	16375	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	:	1780611590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY BURKE JACKSON M.D.

Provider Business Mailing Address
First Line	:	125 N 6TH ST
Second Line	:
City	:	CLARKSBURG
State	:	WV
Zip	:	26301-2665
Country	:	US
Telephone Number	:	304-624-7200
Fax Number	:	304-636-8825

Provider Business Practice Location Address
First Line	:	100 SENECA RD
Second Line	:
City	:	ELKINS
State	:	WV
Zip	:	26241-9709
Country	:	US
Telephone Number	:	304-637-2777
Fax Number	:	304-636-8825

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	01/23/2015

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