Provider Demographics
NPI:1144262288
Name:JACKSON, CHERYL A (MD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3117
Mailing Address - Country:US
Mailing Address - Phone:215-528-5600
Mailing Address - Fax:
Practice Address - Street 1:5901 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3117
Practice Address - Country:US
Practice Address - Phone:215-528-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0010168207R00000X
MDD0046694207R00000X
PAMD469234207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCB9277OtherR/R MEDICARE #
MD376951800Medicaid
MD110115101OtherR/R MEDICARE PROVIDER #
MDS589387MMedicare PIN
MD110115101OtherR/R MEDICARE PROVIDER #