Individual
DR. THEODORE A. JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1306 KANAWHA BLVD E, SUITE 100, CHARLESTON, WV 25301-3001
(304) 342-1113
(304) 346-2271
Mailing address
1306 KANAWHA BLVD E, SUITE 100, CHARLESTON, WV 25301-3001
(304) 342-1113
(304) 346-2271
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
13531
WV
2082S0105X
Surgery of the Hand (Plastic Surgery) Physician
13531
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0051155000
—
WV
Enumeration date
08/31/2005
Last updated
03/12/2009
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