Provider Demographics
NPI:1699322578
Name:JACKSON, RUSSELL PATRICK
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PATRICK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1753 E CORTEZ DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6319
Mailing Address - Country:US
Mailing Address - Phone:801-310-0819
Mailing Address - Fax:
Practice Address - Street 1:301 E COTTONWOOD LN STE 1&2
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2551
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:520-340-4359
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ8654363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program