Basic Information
| Provider Information | |||||||||
| NPI: | 1013131994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | FREEMAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 GREEN VALLEY ROAD | ||||||||
| Address2: | 304 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362824840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 GREEN VALLEY ROAD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362824840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2009-00104 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | P00969101 | 01 | NC | RAILROAD-MEDICARE | OTHER |