Provider Demographics
NPI:1033986021
Name:JACKSON, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12504 N STONE RING DR
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-8101
Mailing Address - Country:US
Mailing Address - Phone:520-955-9299
Mailing Address - Fax:
Practice Address - Street 1:1570 E TUCSON MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6568
Practice Address - Country:US
Practice Address - Phone:520-301-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10630363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical