Provider Demographics
NPI:1669163648
Name:JACKSON, MORGAN WOOD (DDS)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:WOOD
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 1:1542 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2710
Mailing Address - Country:US
Mailing Address - Phone:541-760-7917
Mailing Address - Fax:
Practice Address - Street 1:614 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1403
Practice Address - Country:US
Practice Address - Phone:606-365-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY109731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty