Individual provider · NPI-1

Carl-Christian Andrew Jackson, MD

Surgery, Pediatric Surgery · Providence, RI

NPI number1235355173
StatusActive
Last updated in NPPESNov 26, 2025

Details

NPI
1235355173
Entity type
Individual (NPI-1)
Name
Carl-Christian Andrew Jackson
Credential
MD
Sex
Male
Sole proprietor
No
Enumeration date
Apr 18, 2007
Certification date
Nov 26, 2025
Last updated
Nov 26, 2025

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
2086S0120X Surgery, Pediatric SurgeryMD18790RIYes
208G00000X Thoracic Surgery (Cardiothoracic Vascular Surgery)A88272CA
2086S0120X Surgery, Pediatric Surgery231415MA
208600000X Surgery036-106668IL

Practice location

2 Dudley St Ste 190
Providence, RI 02905-3248

Phone 401-228-0623 · Fax 401-868-2319

Mailing address

15 Lasalle Square
Providence, RI 02903

Phone 401-444-3239

Other practice locations

725 Albany Street, Suite 8c
Shapiro Building
Boston, MA 02118

Phone 617-414-5131 · Fax 617-414-3806

750 Washington St
Tufts-Nemc #344
Boston, MA 02111-1526

Phone 617-636-5025

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