Provider Demographics
NPI:1295705473
Name:JACKSON, DOROTHEA ANN-MARIE (MD)
Entity type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:ANN-MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOROTHEA
Other - Middle Name:A
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1850 N CENTRAL AVE
Mailing Address - Street 2:STE 1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4633
Mailing Address - Country:US
Mailing Address - Phone:602-744-4765
Mailing Address - Fax:602-744-4799
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:STE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-744-4765
Practice Address - Fax:602-744-4799
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26228207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ421107Medicaid
050090897OtherMEDICARE RAILROAD
AZ421107Medicaid
AZZ72446Medicare PIN