Individual
PRUDENCE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
900 CATON AVE, BALTIMORE, MD 21229-5201
(410) 368-2014
Mailing address
10515 BILL LILLY CT, LAUREL, MD 20723-1291
(301) 953-2747
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
D37659
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
60609101
BLUE CROSS
MD
01
—
P00213513
RAILROAD MEDICARE
MD
Enumeration date
06/14/2006
Last updated
07/08/2007
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