Provider Demographics
NPI:1578880548
Name:JACKSON, LARRY ARTHUR (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ARTHUR
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 607
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0026
Mailing Address - Country:US
Mailing Address - Phone:541-942-7000
Mailing Address - Fax:541-942-5550
Practice Address - Street 1:1445 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1224
Practice Address - Country:US
Practice Address - Phone:541-942-7000
Practice Address - Fax:541-942-5550
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine