MEDICARE: DENNIS MARK 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	207Q00000X	Family Medicine Physician	70142	NM

General Provider Information

NPI Number	:	1073687372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS MARK JACKSON MD

Provider Business Mailing Address
First Line	:	MSC06 3870 1 UNIV OF NM
Second Line	:	UNM STUDENT HEALTH CENTER
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87131-0001
Country	:	US
Telephone Number	:	505-277-3136
Fax Number	:	505-277-5668

Provider Business Practice Location Address
First Line	:	MSC06 3870 1 UNIVERSITY OF NEW MEXICO
Second Line	:	UNM STUDENT HEALTH CENTER
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87131-0001
Country	:	US
Telephone Number	:	505-277-3136
Fax Number	:	505-277-5668

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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