Healthcare Provider Details

I. General information

NPI: 1386015121
Provider Name (Legal Business Name): AMY JACKSON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 CAMINO DE MONTE REY A3
SANTA FE NM
87505-3977
US

IV. Provider business mailing address

826 CAMINO DE MONTE REY A3
SANTA FE NM
87505-3977
US

V. Phone/Fax

Practice location:
  • Phone: 500-598-8963
  • Fax: 505-988-9723
Mailing address:
  • Phone: 500-598-8963
  • Fax: 505-988-9723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2112
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: