Provider Demographics
NPI:1063565810
Name:JACKSON, ALISON W (MD)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3577 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4028
Mailing Address - Country:US
Mailing Address - Phone:970-247-8008
Mailing Address - Fax:970-247-8006
Practice Address - Street 1:3577 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4028
Practice Address - Country:US
Practice Address - Phone:970-247-8008
Practice Address - Fax:970-247-8006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01348887Medicaid
CO01348887Medicaid
COC515008Medicare PIN