Provider Demographics
NPI:1124113246
Name:JACKSON, ERNEST W (DDS)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 W TRUMAN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4970
Mailing Address - Country:US
Mailing Address - Phone:573-635-5315
Mailing Address - Fax:573-635-5512
Practice Address - Street 1:111 S MERAMEC AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1711
Practice Address - Country:US
Practice Address - Phone:314-615-8153
Practice Address - Fax:314-615-8303
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0149691223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO406024208Medicaid