Provider Demographics
NPI:1174348155
Name:JACKSON, JASON (BS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66255
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87193-6255
Mailing Address - Country:US
Mailing Address - Phone:505-459-0025
Mailing Address - Fax:505-899-8372
Practice Address - Street 1:10052 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4020
Practice Address - Country:US
Practice Address - Phone:505-459-0025
Practice Address - Fax:505-899-8372
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator