Provider Demographics
NPI:1528833340
Name:JACKSON, JAMES III
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:JACKSON
Suffix:III
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 1:111 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7222
Mailing Address - Country:US
Mailing Address - Phone:857-275-6438
Mailing Address - Fax:
Practice Address - Street 1:111 GREEN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7222
Practice Address - Country:US
Practice Address - Phone:857-275-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator