Provider Demographics
NPI:1245261064
Name:JACKSON, BRIAN GENE (PAC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:GENE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19021 US HIGHWAY 285
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-9410
Mailing Address - Country:US
Mailing Address - Phone:719-376-2308
Mailing Address - Fax:719-274-6065
Practice Address - Street 1:509 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-376-2308
Practice Address - Fax:719-376-2395
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07008436Medicaid
CO07008436Medicaid