MEDICARE: J CARVEL JACKSON D.O.

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	207RA0401X	Addiction Medicine (Internal Medicine) Physician	2543	AZ
2	208100000X	Physical Medicine & Rehabilitation Physician	2543	AZ

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	:	1942262399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	J CARVEL JACKSON D.O.

Provider Business Mailing Address
First Line	:	303 N CENTENNIAL WAY
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-6733
Country	:	US
Telephone Number	:	480-649-3111
Fax Number	:	480-649-3113

Provider Business Practice Location Address
First Line	:	303 N CENTENNIAL WAY
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-6733
Country	:	US
Telephone Number	:	480-649-3111
Fax Number	:	480-649-3113

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	02/02/2023

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