Provider Demographics
NPI:1114507795
Name:LAW, JACKSON DUANE (DPM)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:DUANE
Last Name:LAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 N 57TH AVE RM J210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6993
Mailing Address - Country:US
Mailing Address - Phone:480-861-3804
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program