Basic Information
| Provider Information | |||||||||
| NPI: | 1912165234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22265 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967846 | ||||||||
| FaxNumber: | 8032969699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD | ||||||||
| Address2: | LOWER LEVEL SUITE L9/L10 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346812 | ||||||||
| FaxNumber: | 8034347306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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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 | 207XX0004X | 37261 | SC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207X00000X | 37261 | SC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 372616 | 05 | SC | MEDICAID |