Provider Demographics
NPI:1053667451
Name:CECILY L. JACKSON, DDS, P.C.
Entity Type:Organization
Organization Name:CECILY L. JACKSON, DDS, P.C.
Other - Org Name:JACKSON PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CECILY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-789-9870
Mailing Address - Street 1:21 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:RANSOM CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79366-2517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3233 63RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-5742
Practice Address - Country:US
Practice Address - Phone:806-789-9870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty