Basic Information
| Provider Information | |||||||||
| NPI: | 1578880548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 607 | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974240026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419427000 | ||||||||
| FaxNumber: | 5419425550 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974241224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419427000 | ||||||||
| FaxNumber: | 5419425550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD08513 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.