Provider Demographics
NPI:1861519035
Name:JACKSON, JESSICA ROSE (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6044
Mailing Address - Country:US
Mailing Address - Phone:541-342-2477
Mailing Address - Fax:
Practice Address - Street 1:911 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 222
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6044
Practice Address - Country:US
Practice Address - Phone:541-342-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist