Provider Demographics
NPI:1790396802
Name:JACKSON, JORDAN N (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 TUCKERMAN LN APT 544
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-7318
Mailing Address - Country:US
Mailing Address - Phone:240-383-7676
Mailing Address - Fax:
Practice Address - Street 1:8955 WOOD RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5628
Practice Address - Country:US
Practice Address - Phone:301-295-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD170201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice