Provider Demographics
NPI:1619975398
Name:JACKSON, RODNEY MARK (MD,FAAP)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:MARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD,FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 W ANTHEM WAY
Mailing Address - Street 2:SUITE B-114
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0455
Mailing Address - Country:US
Mailing Address - Phone:623-551-0442
Mailing Address - Fax:623-551-7389
Practice Address - Street 1:3654 W ANTHEM WAY
Practice Address - Street 2:SUITE B-114
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-0455
Practice Address - Country:US
Practice Address - Phone:623-551-0442
Practice Address - Fax:623-551-7389
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ576077Medicaid