MEDICARE: CHRISTINE 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	207RC0000X	Cardiovascular Disease Physician	13940	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861476889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE JACKSON MD

Provider Business Mailing Address
First Line	:	PO BOX 1120
Second Line	:
City	:	EAGAR
State	:	AZ
Zip	:	85925-1120
Country	:	US
Telephone Number	:	928-333-1030
Fax Number	:	928-333-1033

Provider Business Practice Location Address
First Line	:	162 W CENTRAL AVE
Second Line	:
City	:	EAGAR
State	:	AZ
Zip	:	85925-9707
Country	:	US
Telephone Number	:	928-333-1030
Fax Number	:	928-333-1033

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	01/04/2010

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