Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 4242 | CO |
NPI | 1912079641 |
---|---|
Provider Name | Dr. David Christopher Jackson |
First Address | Durango, CO 81301-6815 |
Second Address | Durango, CO 81303-7992 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U62759 | (02) | CO |