Healthcare Provider Details

I. General information

NPI: 1346633161
Provider Name (Legal Business Name): J RYAN JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 E BASELINE RD STE 104
MESA AZ
85209-4376
US

IV. Provider business mailing address

8405 E BASELINE RD STE 104
MESA AZ
85209-4376
US

V. Phone/Fax

Practice location:
  • Phone: 480-674-3295
  • Fax:
Mailing address:
  • Phone: 480-674-3295
  • Fax: 725-239-7974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number007930
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number007930
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: