Individual
RANDY D JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
200 SOMERSET ST, SUITE 2, MILLINOCKET, ME 04462-1258
(207) 723-5173
(207) 723-3040
Mailing address
200 SOMERSET ST, MILLINOCKET, ME 04462-1258
(207) 723-5173
(207) 723-3040
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-028
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
079032
ANTHEM
ME
05
—
1508825357
—
ME
01
—
201855
NGS
ME
Enumeration date
03/21/2006
Last updated
02/11/2013
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