Provider Demographics
NPI:1295944072
Name:SIMMONS, JACKIE ROSS
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:ROSS
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26058 TAOS CANYON, HWY 64
Mailing Address - Street 2:HC 71 BOX 77
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-9501
Mailing Address - Country:US
Mailing Address - Phone:505-758-8309
Mailing Address - Fax:
Practice Address - Street 1:622 PASEO DEL PUEBLO SUR STE A
Practice Address - Street 2:5401 NDCBU
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5101
Practice Address - Country:US
Practice Address - Phone:505-758-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist