Provider Demographics
NPI:1740530302
Name:JACKSON, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:
Practice Address - Street 1:1441 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-5420
Practice Address - Country:US
Practice Address - Phone:208-642-9376
Practice Address - Fax:208-642-9279
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD187049207Q00000X
IDM-14093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-14093OtherSTATE OF IDAHO MEDICAL LICENSE
ORMD187049OtherSTATE OF OREGON, MEDICAL LICENSE