Provider Demographics
NPI:1972864825
Name:JACKSON, COURTNEY MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:MATTHEW
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:859 S YELLOWSTONE HWY STE 1202
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-6201
Mailing Address - Country:US
Mailing Address - Phone:208-552-5439
Mailing Address - Fax:208-552-5440
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 1202
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6201
Practice Address - Country:US
Practice Address - Phone:208-552-5439
Practice Address - Fax:208-552-5440
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14331223P0221X
IDD-4655-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry