Healthcare Provider Details

I. General information

NPI: 1164963724
Provider Name (Legal Business Name): ARIC JACKSON CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 W 2ND PL
LAKEWOOD CO
80228-1527
US

IV. Provider business mailing address

10200 PARK MEADOWS DR UNIT 531
LITTLETON CO
80124-5460
US

V. Phone/Fax

Practice location:
  • Phone: 720-321-0000
  • Fax:
Mailing address:
  • Phone: 202-420-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0002338
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: