Provider Demographics
NPI:1003456708
Name:JACKSON, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 PARKWAY NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-2522
Mailing Address - Country:US
Mailing Address - Phone:480-466-3423
Mailing Address - Fax:541-229-1293
Practice Address - Street 1:6 PARKWAY NORTH BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-2522
Practice Address - Country:US
Practice Address - Phone:480-466-3423
Practice Address - Fax:541-229-1293
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist