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General NPI Number Information
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NPI Number | 1568863322
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Entity Type | Organization
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Legal Business Name | GRACE E. JACKSON, MD, PLLC
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Dates
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Enumeration Date | 09/11/2014
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Last Update Date | 10/14/2014
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Provider Practice Location Address
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Address Line | 115 S CANDY LN STE C2
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City | COTTONWOOD
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State | AZ
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Zip | 86326-4188
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Country | US
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Telephone | 928-649-6736
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Fax |
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Provider Business Mailing Address
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Address Line | 115 S CANDY LN STE C2
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City | COTTONWOOD
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State | AZ
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Zip | 86326-4188
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Country | US
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Telephone | 928-649-6736
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GRACE E JACKSON
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Credential | MD
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Telephone | 928-649-6736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 46710
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License Number State | AZ
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