Provider Demographics
NPI:1538159710
Name:JACKSON, VICKI (MD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-9197
Mailing Address - Fax:617-724-8693
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:PALLIATIVE CARE SERVICE FND 600
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-9197
Practice Address - Fax:617-724-8693
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA156340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA156340OtherTUFTS HEALTH PLAN
MAJ24683OtherBCBS MA
MA0191639Medicaid
MAJ24683OtherBCBS MA
MA156340OtherTUFTS HEALTH PLAN