Provider Demographics
NPI:1396017265
Name:FERGUSON, JACKSON (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5559
Mailing Address - Country:US
Mailing Address - Phone:970-686-3950
Mailing Address - Fax:970-686-3960
Practice Address - Street 1:1455 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5559
Practice Address - Country:US
Practice Address - Phone:970-686-3950
Practice Address - Fax:970-686-3960
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004074363A00000X
ORPA165403363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical