Provider Demographics
NPI:1598149577
Name:JACKSON, COURTNEY MOORE (DDS)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MOORE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 W LINCOLN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1255
Mailing Address - Country:US
Mailing Address - Phone:414-546-1900
Mailing Address - Fax:
Practice Address - Street 1:10401 W LINCOLN AVE STE 210
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-1255
Practice Address - Country:US
Practice Address - Phone:414-546-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001428151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics