MEDICARE: MR. WILLIAM IVAN JACKSON III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1053917294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM IVAN JACKSON III

Provider Business Mailing Address
First Line	:	7105 HORIZON WOOD LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80927-4117
Country	:	US
Telephone Number	:	719-367-0753
Fax Number	:

Provider Business Practice Location Address
First Line	:	7105 HORIZON WOOD LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80927-4117
Country	:	US
Telephone Number	:	719-367-0753
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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