Provider Demographics
NPI:1194969220
Name:DENNIS M JACKSON MD INC
Entity type:Organization
Organization Name:DENNIS M JACKSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-490-9738
Mailing Address - Street 1:5112 HOLLYWOOD BLVD
Mailing Address - Street 2:#111 PMB 106
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6126
Mailing Address - Country:US
Mailing Address - Phone:505-490-9738
Mailing Address - Fax:
Practice Address - Street 1:460 SAINT MICHAELS DR
Practice Address - Street 2:#1005
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7619
Practice Address - Country:US
Practice Address - Phone:505-490-9738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty