Individual
TIMOTHY JACKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
4540 E BASELINE RD, SUITE 108, MESA, AZ 85206-4613
(480) 892-3880
(480) 545-4551
Mailing address
4540 E BASELINE RD, SUITE 108, MESA, AZ 85206-4613
(480) 892-3880
(480) 545-4551
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
R70095
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R70095
TRAINING PERMIT
AZ
Enumeration date
07/15/2008
Last updated
05/17/2013
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