Basic Information
| Provider Information | |||||||||
| NPI: | 1346701448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11750 BIRD RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331753530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052232000 | ||||||||
| FaxNumber: | 3052275556 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC09 5040 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724661 | ||||||||
| FaxNumber: | 5052720475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2019 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | NM | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.