Provider Demographics
NPI:1891746707
Name:JACKSON, ALFRED VAUGHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED VAUGHN
Middle Name:D
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:PO BOX 272
Mailing Address - Street 2:416 MAIN STREET
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-0272
Mailing Address - Country:US
Mailing Address - Phone:719-274-4500
Mailing Address - Fax:719-274-4504
Practice Address - Street 1:416 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140-0272
Practice Address - Country:US
Practice Address - Phone:719-274-4500
Practice Address - Fax:719-274-4504
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1823241205207Q00000X
NM89132207Q00000X
CO31351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01313519Medicaid
NM89132Medicaid
NM89132Medicaid
CO01313519Medicaid