Provider Demographics
NPI:1073687372
Name:JACKSON, DENNIS MARK (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:MARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:M
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:MSC06 3870 1 UNIV OF NM
Mailing Address - Street 2:UNM STUDENT HEALTH CENTER
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-3136
Mailing Address - Fax:505-277-5668
Practice Address - Street 1:MSC06 3870 1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:UNM STUDENT HEALTH CENTER
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-277-3136
Practice Address - Fax:505-277-5668
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G24199Medicare UPIN