Provider Demographics
NPI:1184067498
Name:JACKSON, CHAD HARMAN (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:HARMAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7308
Mailing Address - Country:US
Mailing Address - Phone:208-344-3220
Mailing Address - Fax:208-344-0461
Practice Address - Street 1:111 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7308
Practice Address - Country:US
Practice Address - Phone:208-344-3220
Practice Address - Fax:208-344-0461
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67198207W00000X
NV18691207WX0200X
IDM-15230207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184067498Medicaid