Individual
BRUCE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN, FA
Contact information
Practice address
2828 1ST AVE STE 400, HUNTINGTON, WV 25702-1236
(304) 525-6905
(304) 525-4316
Mailing address
2828 1ST AVE STE 400, HUNTINGTON, WV 25702-1236
(304) 525-6905
(304) 525-4316
Taxonomy
Speciality
Code
Description
License number
State
163WX0800X
Orthopedic Registered Nurse
398466
OH
163WX0800X
Orthopedic Registered Nurse
Primary
60256
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0010681000
—
WV
05
—
352265
—
OH
Enumeration date
09/09/2015
Last updated
09/09/2015
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