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Individual
ROBERT E JACKSON JR.
Active
Individual
ROBERT E JACKSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
10879
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
018797
—
SC
01
—
080075169
RR MCR
—
01
—
SCG5856067
MEDICARE PIN
SC
01
—
SCG5856084
MEDICARE PIN
SC
01
—
SCG585J577
MEDICARE PIN
SC
Enumeration date
01/03/2006
Last updated
01/21/2021
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