Provider Demographics
NPI:1164034948
Name:JACKMAN, CLIFTON E
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:E
Last Name:JACKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SANSOM CT
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1600
Mailing Address - Country:US
Mailing Address - Phone:304-736-4148
Mailing Address - Fax:
Practice Address - Street 1:5 SANSOM CT
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1600
Practice Address - Country:US
Practice Address - Phone:304-736-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant