Provider Demographics
NPI:1912127242
Name:JACKSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 S SANTA CRUZ ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-5439
Mailing Address - Country:US
Mailing Address - Phone:505-546-6237
Mailing Address - Fax:
Practice Address - Street 1:215 S SILVER AVE
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-3715
Practice Address - Country:US
Practice Address - Phone:505-546-2771
Practice Address - Fax:505-546-9427
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR47234163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health