Provider Demographics
NPI:1528719416
Name:JACKSON, ROBIN (DAC)
Entity type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3894
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3894
Mailing Address - Country:US
Mailing Address - Phone:928-853-8301
Mailing Address - Fax:
Practice Address - Street 1:2905 N WEST ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3443
Practice Address - Country:US
Practice Address - Phone:928-679-0795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-010066171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist