Provider Demographics
NPI:1093040701
Name:JACKSON, MARIE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FIFTY ROUTE FIFTEEN NORTH
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07848
Mailing Address - Country:US
Mailing Address - Phone:973-579-7888
Mailing Address - Fax:973-579-7865
Practice Address - Street 1:50 ROUTE 15
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:NJ
Practice Address - Zip Code:07848
Practice Address - Country:US
Practice Address - Phone:973-579-7888
Practice Address - Fax:973-579-7865
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024147001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice