Provider Demographics
NPI:1427020957
Name:JACKMON, WALLACE J (PHD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:J
Last Name:JACKMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:STE 1500
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8170
Practice Address - Country:US
Practice Address - Phone:605-322-5700
Practice Address - Fax:605-322-5704
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD477103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12200Medicaid
NE46022474352Medicaid
SD854000OtherARAZ/ AMERICA'S PPO
MN944611700Medicaid
SD0040537OtherBLUE CROSS
MN140M8JAOtherCC SYSTEMS/ BLUE PLUS
MN142415OtherUCARE
SD412991020844OtherPREFERRED ONE
SD6552790Medicaid
SD6570753Medicaid
SD800013808OtherRR MEDICARE
SDHP37115OtherHEALTHPARTNERS
SD15096OtherMIDLANDS CHOICE
SD20814OtherSANFORD HEALTH PLAN
IA3989442Medicaid
SD57108C003OtherWPS TRICARE
SD9205351OtherDAKOTACARE
MN040121002OtherPRIMEWEST
SD9205351OtherDAKOTACARE
SDHP37115OtherHEALTHPARTNERS
IA3989442Medicaid