Provider Demographics
NPI:1114619459
Name:JACKSON, SALLY FAYRWEATHER (HRN)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:FAYRWEATHER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 E BASELINE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2739
Mailing Address - Country:US
Mailing Address - Phone:480-590-5833
Mailing Address - Fax:
Practice Address - Street 1:3303 E BASELINE RD STE 108
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2739
Practice Address - Country:US
Practice Address - Phone:480-590-5833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12Z3145002055207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine