Healthcare Provider Details

I. General information

NPI: 1588657795
Provider Name (Legal Business Name): DARRELL JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 MULLINS AVE
ALAMOSA CO
81101
US

IV. Provider business mailing address

2405 MULLINS AVE
ALAMOSA CO
81101
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-5272
  • Fax: 719-589-5300
Mailing address:
  • Phone: 719-589-5272
  • Fax: 719-589-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8293
License Number StateCO

VIII. Authorized Official

Name: DR. DARRELL GILBERT JACKSON
Title or Position: OWNER
Credential: D.D.S.
Phone: 719-589-5272