Basic Information
| Provider Information | |||||||||
| NPI: | 1346633161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | J | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 36359 N GANTZEL RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851407332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806361193 | ||||||||
| FaxNumber: | 4806643661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2015 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 007930 | AZ | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.