Provider Demographics
NPI:1467619056
Name:JACKSON, JOHN P (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S FRANKLIN ST
Mailing Address - Street 2:PO BOX 612
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2516
Mailing Address - Country:US
Mailing Address - Phone:573-756-6415
Mailing Address - Fax:573-756-6416
Practice Address - Street 1:109 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2516
Practice Address - Country:US
Practice Address - Phone:573-756-6415
Practice Address - Fax:573-756-6416
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist