Healthcare Provider Details

I. General information

NPI: 1417347055
Provider Name (Legal Business Name): JACKSON HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 W INDIAN SCHOOL RD SUITE #B210
AVONDAALE AZ
85392
US

IV. Provider business mailing address

PO BOX 11180
TEMPE AZ
85392
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-9920
  • Fax:
Mailing address:
  • Phone: 480-264-3744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS MORGAN
Title or Position: OWNER
Credential: DC
Phone: 623-935-9920