Healthcare Provider Details

I. General information

NPI: 1538373386
Provider Name (Legal Business Name): CATHERINE JACKSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST STE 7
SANTA FE NM
87505-4752
US

IV. Provider business mailing address

5000 CHESHIRE PKWY N
PLYMOUTH MN
55446-4203
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4327
  • Fax: 505-988-4328
Mailing address:
  • Phone: 763-268-4000
  • Fax: 763-268-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1030
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: