Provider Demographics
NPI:1801853775
Name:JACKSON, DAVID A (PHD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 S 31ST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3593
Mailing Address - Country:US
Mailing Address - Phone:701-780-6821
Mailing Address - Fax:701-780-1973
Practice Address - Street 1:3535 S 31ST ST STE 201
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3593
Practice Address - Country:US
Practice Address - Phone:701-780-6821
Practice Address - Fax:701-780-1973
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND359103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN169230500Medicaid
ND12028Medicaid
MN65F61JAOtherMN BC/BS
ND22269OtherND BC/BS