Provider Demographics
NPI:1821359795
Name:JACKSON, MATTHEW WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD UNIT 160
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3413
Mailing Address - Country:US
Mailing Address - Phone:970-482-3328
Mailing Address - Fax:970-482-1433
Practice Address - Street 1:2121 E HARMONY RD UNIT 160
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3413
Practice Address - Country:US
Practice Address - Phone:970-482-3328
Practice Address - Fax:970-482-1433
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.00046442085R0001X
390200000X
CODR.00705272085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program