Individual
BRIAN GENE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
509 MAIN STREET, LA JARA, CO 81140
(719) 376-2308
(719) 376-2395
Mailing address
19021 US HIGHWAY 285, LA JARA, CO 81140-9410
(719) 376-2308
(719) 274-6065
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
843
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07008436
—
CO
Enumeration date
07/06/2006
Last updated
05/06/2021
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