Provider Demographics
NPI:1710114582
Name:JACKSON, RYAN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7509
Mailing Address - Fax:314-362-7522
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DEPT OTOLARYNGOLOGY, STE 11A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7509
Practice Address - Fax:314-362-7522
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015010898207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200022003Medicaid