Healthcare Provider Details

I. General information

NPI: 1760115992
Provider Name (Legal Business Name): JERMAL JACKSON RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTES N12 & N7
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

8226 MENAUL BLVD NE # 556
ALBUQUERQUE NM
87110-4614
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2279P3900X
TaxonomyNeonatal/Pediatric Registered Respiratory Therapist
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: