1730281429 NPI number — JEFFREY A JACKSON PAC

Table of content: JEFFREY A JACKSON PAC (NPI 1730281429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730281429 NPI number — JEFFREY A JACKSON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JEFFREY
Provider Middle Name:
A
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:
1730281429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-628-9566
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3703 OAKWOOD HILLS PKWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-4458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
534-444-4562
Provider Business Practice Location Address Fax Number:
534-444-4563
Provider Enumeration Date:
09/02/2006

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:  562 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

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




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