Provider Demographics
NPI:1508000480
Name:JACKSON, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:PINON
Mailing Address - State:AZ
Mailing Address - Zip Code:86510-0010
Mailing Address - Country:US
Mailing Address - Phone:928-725-9500
Mailing Address - Fax:
Practice Address - Street 1:NAVAJO ROUTE 4
Practice Address - Street 2:PINON HEALTH CENTER
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510
Practice Address - Country:US
Practice Address - Phone:928-725-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099840207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics