Provider Demographics
NPI:1639664527
Name:JACKSON, MERSEDES S (DDS)
Entity type:Individual
Prefix:
First Name:MERSEDES
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
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:KENNER ARMY HEALTH CENTER
Mailing Address - Street 2:700 24TH STREET
Mailing Address - City:FORT GREGG-ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801
Mailing Address - Country:US
Mailing Address - Phone:804-734-5365
Mailing Address - Fax:
Practice Address - Street 1:KENNER ARMY HEALTH CLINIC
Practice Address - Street 2:700 24TH STREET
Practice Address - City:FORT GREGG-ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801
Practice Address - Country:US
Practice Address - Phone:804-734-5365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist