Healthcare Provider Details

I. General information

NPI: 1801853775
Provider Name (Legal Business Name): DAVID A JACKSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S 31ST ST STE 201
GRAND FORKS ND
58201-3593
US

IV. Provider business mailing address

3535 S 31ST ST STE 201
GRAND FORKS ND
58201-3593
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6821
  • Fax: 701-780-1973
Mailing address:
  • Phone: 701-780-6821
  • Fax: 701-780-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number359
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: