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General NPI Number Information
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NPI Number | 1891746707
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Entity Type | Individual
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Provider Name | ALFRED VAUGHN D JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 11/13/2013
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Provider Practice Location Address
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Address Line | 416 MAIN STREET
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City | LA JARA
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State | CO
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Zip | 81140-0272
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Country | US
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Telephone | 719-274-4500
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Fax | 719-274-4504
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Provider Business Mailing Address
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Address Line | PO BOX 272 416 MAIN STREET
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City | LA JARA
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State | CO
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Zip | 81140-0272
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Country | US
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Telephone | 719-274-4500
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Fax | 719-274-4504
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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 | 1823241205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 89132
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 31351
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License Number State | CO
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