Healthcare Provider Details

I. General information

NPI: 1407595689
Provider Name (Legal Business Name): ANTHONY RASHAD JACKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N 5TH ST
PHOENIX AZ
85004-2157
US

IV. Provider business mailing address

12806 W HEARN RD
EL MIRAGE AZ
85335-7308
US

V. Phone/Fax

Practice location:
  • Phone: 602-827-2450
  • Fax:
Mailing address:
  • Phone: 404-578-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9352
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: