Provider Demographics
NPI:1861476889
Name:JACKSON, CHRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
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:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-1120
Mailing Address - Country:US
Mailing Address - Phone:928-333-1030
Mailing Address - Fax:928-333-1033
Practice Address - Street 1:162 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9707
Practice Address - Country:US
Practice Address - Phone:928-333-1030
Practice Address - Fax:928-333-1033
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13940207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274613Medicaid
AZ274613Medicaid
AZZ106912Medicare PIN