Randy D Jackson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA-028 Issued in ME

Practice address

200 Somerset St
Suite 2
Millinocket, ME 04462-1258

Phone

(207) 723-5173

Fax

(207) 723-3040

NPI assigned

Mar 21, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Health Access Network, Inc.

  dba Health Access Family Dental

  • Federally Qualified Health Center (FQHC)
  • Lincoln, ME
  • NPI 1295993616
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142899200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1360540800000",
    "number": "1508825357",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 SOMERSET ST",
            "city": "MILLINOCKET",
            "state": "ME",
            "postal_code": "044621258",
            "telephone_number": "207-723-5173",
            "fax_number": "207-723-3040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 SOMERSET ST",
            "address_2": "SUITE 2",
            "city": "MILLINOCKET",
            "state": "ME",
            "postal_code": "044621258",
            "telephone_number": "207-723-5173",
            "fax_number": "207-723-3040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "RANDY",
        "middle_name": "D",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-21",
        "last_updated": "2013-02-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "ME",
            "license": "PA-028",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "079032",
            "state": "ME"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NGS",
            "identifier": "201855",
            "state": "ME"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1508825357",
            "state": "ME"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Daniel C Herbert, M.D.
• Tammy Hill, PTA
• Rose Ann Hunt, NP
• Brendan D Hurley, DC
• Cynthia E Ingerson
• Stephannie Jacobs, RN
• Deborha Jander-Piergross, RN
• David P Johnson, PA
• Josh H Jones, RN
• Thomas Edward Jones II, MOTR/L

• Physician Assistant in Millinocket, ME
• Providers in Millinocket, ME by specialty
• Physician Assistant in Maine

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.