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General NPI Number Information
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NPI Number | 1972864825
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Entity Type | Individual
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Provider Name | COURTNEY MATTHEW JACKSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/06/2012
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 859 S YELLOWSTONE HWY STE 1202
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City | REXBURG
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State | ID
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Zip | 83440-6201
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Country | US
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Telephone | 208-552-5439
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Fax | 208-552-5440
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Provider Business Mailing Address
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Address Line | 859 S YELLOWSTONE HWY STE 1202
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City | REXBURG
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State | ID
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Zip | 83440-6201
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Country | US
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Telephone | 208-552-5439
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Fax | 208-552-5440
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 1433
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D-4655-PD
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License Number State | ID
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