Healthcare Provider Details

I. General information

NPI: 1780339564
Provider Name (Legal Business Name): COLTON WORTH JACKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2022
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE BLDG D
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2200
  • Fax:
Mailing address:
  • Phone: 505-412-7467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0118
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: