1245261064 NPI number — BRIAN GENE JACKSON PAC

Table of content: BRIAN GENE JACKSON PAC (NPI 1245261064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245261064 NPI number — BRIAN GENE JACKSON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
BRIAN
Provider Middle Name:
GENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245261064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19021 US HIGHWAY 285
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JARA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81140-9410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-376-2308
Provider Business Mailing Address Fax Number:
719-274-6065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JARA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-376-2308
Provider Business Practice Location Address Fax Number:
719-376-2395
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  843 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07008436 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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