Provider Demographics
NPI:1336234640
Name:JACKSON, HARRY KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:KEITH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-720-4466
Mailing Address - Fax:304-720-4813
Practice Address - Street 1:116 HILLS PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2438
Practice Address - Country:US
Practice Address - Phone:304-720-4466
Practice Address - Fax:304-720-4813
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1336234640Medicaid
WV0135354000Medicaid