MEDICARE: DR. JOHN P JACKSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	11953	MO

General Provider Information

NPI Number	:	1467619056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN P JACKSON DDS

Provider Business Mailing Address
First Line	:	109 S FRANKLIN ST
Second Line	:	PO BOX 612
City	:	FARMINGTON
State	:	MO
Zip	:	63640-2516
Country	:	US
Telephone Number	:	573-756-6415
Fax Number	:	573-756-6416

Provider Business Practice Location Address
First Line	:	109 S FRANKLIN ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-2516
Country	:	US
Telephone Number	:	573-756-6415
Fax Number	:	573-756-6416

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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Directions to “ DR. JOHN P JACKSON DDS” Practice Location

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