Provider Demographics
NPI:1518005610
Name:TERESA L JACKSON MD PC
Entity Type:Organization
Organization Name:TERESA L JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-531-0700
Mailing Address - Street 1:PO BOX 43100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3100
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:1521 E TANGERINE RD
Practice Address - Street 2:#331
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6225
Practice Address - Country:US
Practice Address - Phone:520-531-0700
Practice Address - Fax:520-531-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32627208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105932Medicare ID - Type Unspecified