Provider Demographics
NPI:1235786013
Name:JACKSON, CHELSEA LYNN
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 W WEBSTER CT
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1854
Mailing Address - Country:US
Mailing Address - Phone:602-405-5998
Mailing Address - Fax:
Practice Address - Street 1:42201 N 41ST DR STE 156
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3803
Practice Address - Country:US
Practice Address - Phone:623-551-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025964122300000X
AZD010374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist