Provider Demographics
NPI:1568863322
Name:GRACE E. JACKSON, MD, PLLC
Entity Type:Organization
Organization Name:GRACE E. JACKSON, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-649-6736
Mailing Address - Street 1:115 S CANDY LN STE C2
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4188
Mailing Address - Country:US
Mailing Address - Phone:928-649-6736
Mailing Address - Fax:
Practice Address - Street 1:115 S CANDY LN STE C2
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4188
Practice Address - Country:US
Practice Address - Phone:928-649-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ467102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty