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General NPI Number Information
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NPI Number | 1134565849
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Entity Type | Organization
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Legal Business Name | LARRY A. JACKSON, MD PC
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Dates
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Enumeration Date | 05/21/2013
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Last Update Date | 05/21/2013
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Provider Practice Location Address
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Address Line | 1717 CENTENNIAL BLVD SUITE 7
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City | SPRINGFIELD
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State | OR
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Zip | 97477-3378
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Country | US
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Telephone | 541-726-0550
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Fax | 541-726-7485
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Provider Business Mailing Address
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Address Line | 1717 CENTENNIAL BLVD SUITE 7
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City | SPRINGFIELD
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State | OR
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Zip | 97477-3378
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Country | US
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Telephone | 541-726-0550
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Fax | 541-726-7485
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LARRY ARTHUR JACKSON
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Credential | MD
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Telephone | 541-726-0550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 08513
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License Number State | OR
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