MEDICARE: CASSANDRA RAY JACKSON MD

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	2084P0800X	Psychiatry Physician	0615	SD
2	2084P0800X	Psychiatry Physician	72875	MN
3	390200000X	Student in an Organized Health Care Education/Training Program		SD

General Provider Information

NPI Number	:	1053998781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA RAY JACKSON MD

Provider Business Mailing Address
First Line	:	4400 W 69TH ST STE 500
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8171
Country	:	US
Telephone Number	:	605-988-4781
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 W 69TH ST STE 500
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8171
Country	:	US
Telephone Number	:	605-322-5700
Fax Number	:

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

Provider Enumeration Date	:	03/27/2021
Last Update Date	:	05/05/2026

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