Provider Demographics
NPI:1780985119
Name:JACKSON, SIONEY L (DENTIST)
Entity type:Individual
Prefix:DR
First Name:SIONEY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7433 N. FIRST ST.
Mailing Address - Street 2:SUITE #101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-447-3003
Mailing Address - Fax:559-432-7824
Practice Address - Street 1:7433 N. FIRST ST.
Practice Address - Street 2:SUITE #101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-447-3003
Practice Address - Fax:559-432-7824
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist