Healthcare Provider Details

I. General information

NPI: 1174348155
Provider Name (Legal Business Name): JASON JACKSON BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10052 COORS BLVD NW
ALBUQUERQUE NM
87114-4020
US

IV. Provider business mailing address

PO BOX 66255
ALBUQUERQUE NM
87193-6255
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-0025
  • Fax: 505-899-8372
Mailing address:
  • Phone: 505-459-0025
  • Fax: 505-899-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: