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General NPI Number Information
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NPI Number | 1326931742
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Entity Type | Individual
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Provider Name | BENJAMIN JOSEPH JACKSON DMD
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Gender | Male
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Dates
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Enumeration Date | 06/03/2025
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 7017 JOHN DEERE PKWY STE 2B
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City | MOLINE
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State | IL
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Zip | 61265-8037
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Country | US
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Telephone | 309-792-0513
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Fax |
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Provider Business Mailing Address
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Address Line | 5101 LAKEVIEW PKWY UNIT 409
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City | DAVENPORT
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State | IA
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Zip | 52807-3311
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Country | US
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Telephone | 501-617-1107
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.036026
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License Number State | IL
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