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General NPI Number Information
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NPI Number | 1598170193
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Entity Type | Individual
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Provider Name | NEIL CHRISTOPHER JACKSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/23/2014
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Last Update Date | 01/05/2024
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Provider Practice Location Address
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Address Line | 2022 E AZTEC AVE
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City | GALLUP
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State | NM
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Zip | 87301-4804
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Country | US
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Telephone | 505-397-5172
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Fax |
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Provider Business Mailing Address
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Address Line | 615 VANDENBOSCH PKWY
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City | GALLUP
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State | NM
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Zip | 87301-4537
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Country | US
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Telephone | 412-445-4695
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD2019-0691
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License Number State | NM
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