Provider Demographics
NPI:1083812366
Name:JACKSON, SAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
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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Mailing Address - Street 1:925 E MCDOWELL RD
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2502
Mailing Address - Country:US
Mailing Address - Phone:602-239-2280
Mailing Address - Fax:602-239-4138
Practice Address - Street 1:925 E MCDOWELL RD
Practice Address - Street 2:FLOOR 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2502
Practice Address - Country:US
Practice Address - Phone:602-239-2280
Practice Address - Fax:602-239-4138
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ35554207P00000X
AZ77351207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology