Provider Demographics
NPI:1467974253
Name:JACKSON, ANN MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 VALLEY VIEW AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3670
Mailing Address - Country:US
Mailing Address - Phone:304-667-0164
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR RM 1200
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-293-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1841271459OtherWV CHIP
WV1841271459Medicaid