Provider Demographics
NPI:1538373386
Name:JACKSON, CATHERINE (MA)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4203
Mailing Address - Country:US
Mailing Address - Phone:763-268-4000
Mailing Address - Fax:763-268-4017
Practice Address - Street 1:1651 GALISTEO ST STE 7
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4752
Practice Address - Country:US
Practice Address - Phone:505-988-4327
Practice Address - Fax:505-988-4328
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1030237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM532OtherSTATE HEARING AID DISPENS
NM1030OtherSTATE LICENSE NUMBER
NMK2469Medicaid