Provider Demographics
NPI:1659460814
Name:JACKSON, GRACE E (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:127 LINDA VIS
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5069
Mailing Address - Country:US
Mailing Address - Phone:928-554-1022
Mailing Address - Fax:928-554-1023
Practice Address - Street 1:115 S CANDY LN
Practice Address - Street 2:SUITE C2
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4105
Practice Address - Country:US
Practice Address - Phone:928-649-6736
Practice Address - Fax:928-649-6738
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV153202084P0800X
NC2002009222084P0800X
WY12228A2084P0800X
CAC560012084P0800X
HIMD-171012084P0800X
TN632172084P0800X
AZ467102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913321Medicaid
AZ765156Medicaid