Provider Demographics
NPI:1548376437
Name:JACKSON, JOHN ROBERT (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MACINTOSH DR
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:NORTHERN RHODE ISLAND ANESTHESIA ASSOCIATES, PC
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206366367500000X
RIAPRN00396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007057814Medicare ID - Type UnspecifiedRHODE ISLAND MEDICARE
MANA1105Medicare ID - Type UnspecifiedMASSACHUSETTS MEDICARE