Healthcare Provider Details

I. General information

NPI: 1598170193
Provider Name (Legal Business Name): NEIL CHRISTOPHER JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 E AZTEC AVE
GALLUP NM
87301-4804
US

IV. Provider business mailing address

615 VANDENBOSCH PKWY
GALLUP NM
87301-4537
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax:
Mailing address:
  • Phone: 412-445-4695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2019-0691
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: