Provider Demographics
NPI:1700535861
Name:JACKSON, MATTHEW RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2603
Mailing Address - Country:US
Mailing Address - Phone:910-592-8511
Mailing Address - Fax:
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-435-8828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL87625207Q00000X
NC2025-01455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine