Provider Demographics
NPI:1992757728
Name:JACKSON, LINDA A (DDS)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:A
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 1:301 BECKER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3302
Mailing Address - Country:US
Mailing Address - Phone:320-214-2620
Mailing Address - Fax:320-214-2630
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:RICE REGIONAL DENTAL CLINIC
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3302
Practice Address - Country:US
Practice Address - Phone:320-214-2620
Practice Address - Fax:320-214-2630
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020810122300000X
MNFF46122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
585241041522OtherPREFERRED ONE
MN382100500Medicaid