Provider Demographics
NPI:1972610947
Name:JACKSON, TIMOTHY MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:ELBA
Mailing Address - State:AL
Mailing Address - Zip Code:36323
Mailing Address - Country:US
Mailing Address - Phone:334-897-3418
Mailing Address - Fax:334-897-3438
Practice Address - Street 1:982 DRAYTON AVENUE
Practice Address - Street 2:
Practice Address - City:ELBA
Practice Address - State:AL
Practice Address - Zip Code:36323
Practice Address - Country:US
Practice Address - Phone:334-897-3418
Practice Address - Fax:334-897-3438
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist