Provider Demographics
NPI:1659675361
Name:JACKSON, CLINTON O
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:O
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
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 671288
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-1288
Mailing Address - Country:US
Mailing Address - Phone:907-694-6161
Mailing Address - Fax:
Practice Address - Street 1:12244 BRECKENRIDGE DR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7656
Practice Address - Country:US
Practice Address - Phone:907-694-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1090102237700000X
AK92237700000X
CA117575237700000X
CA107575237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist