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General NPI Number Information
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NPI Number | 1164686549
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Entity Type | Individual
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Provider Name | TIMOTHY JACKS D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/15/2008
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Last Update Date | 05/17/2013
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Provider Practice Location Address
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Address Line | 4540 E BASELINE RD SUITE 108
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City | MESA
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State | AZ
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Zip | 85206-4613
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Country | US
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Telephone | 480-892-3880
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Fax | 480-545-4551
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Provider Business Mailing Address
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Address Line | 4540 E BASELINE RD SUITE 108
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City | MESA
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State | AZ
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Zip | 85206-4613
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Country | US
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Telephone | 480-892-3880
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Fax | 480-545-4551
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | R70095
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License Number State | AZ
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