Provider Demographics
NPI:1760535926
Name:JACKSON, CHARLES (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N DALMONT ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-5214
Mailing Address - Country:US
Mailing Address - Phone:505-393-9137
Mailing Address - Fax:505-391-3977
Practice Address - Street 1:820 N DALMONT ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5214
Practice Address - Country:US
Practice Address - Phone:505-393-9137
Practice Address - Fax:505-391-3977
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM239213E00000X
TX1640213E00000X
MS80171213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67753Medicaid
NMNM005310OtherBCBS
NM4562520001Medicare NSC
NM67753Medicaid
OK4562520001Medicare NSC
U53871Medicare UPIN
NM$$$$$$$$$Medicare PIN