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Individual
CHARLES JACKSON
Active
Individual
CHARLES JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
1640
TX
213E00000X
Podiatrist
Primary
239
NM
213E00000X
Podiatrist
80171
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
67753
—
NM
01
—
NM005310
BCBS
NM
Enumeration date
01/19/2007
Last updated
03/06/2012
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