Provider Demographics
NPI:1427117860
Name:JACKSON, JAIH C (DDS, PA)
Entity type:Individual
Prefix:DR
First Name:JAIH
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8358 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5137
Mailing Address - Country:US
Mailing Address - Phone:941-907-9790
Mailing Address - Fax:941-907-3449
Practice Address - Street 1:8358 MARKET ST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-5137
Practice Address - Country:US
Practice Address - Phone:941-907-9790
Practice Address - Fax:941-907-3449
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN150321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice