Provider Demographics
NPI:1225692361
Name:JACKSON, CLAYTON SCOTT (DMD, MSD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-8506
Mailing Address - Country:US
Mailing Address - Phone:812-258-9626
Mailing Address - Fax:812-213-4190
Practice Address - Street 1:3934 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-897-0625
Practice Address - Fax:502-618-4514
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013287A1223P0221X
KY108521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry