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General NPI Number Information
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NPI Number | 1407435696
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Entity Type | Individual
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Provider Name | REYNALDO JACKSON DMD
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Gender | Male
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 09/12/2025
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Provider Practice Location Address
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Address Line | 9521 S WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60643-1013
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Country | US
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Telephone | 773-344-9120
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Fax |
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Provider Business Mailing Address
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Address Line | 10510 GRAVELLY LAKE DR SW
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City | LAKEWOOD
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State | WA
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Zip | 98499-5036
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Country | US
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Telephone | 253-589-7030
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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 | DE61346798
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.036510
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License Number State | IL
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