Provider Demographics
NPI:1225147317
Name:JACKSON, PAMELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 JENNINGS STATION RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-3505
Mailing Address - Country:US
Mailing Address - Phone:314-382-2000
Mailing Address - Fax:314-382-2411
Practice Address - Street 1:3721 JENNINGS STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-3505
Practice Address - Country:US
Practice Address - Phone:314-382-2000
Practice Address - Fax:314-382-2411
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist