Individual
TYSON A JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1100 CENTRAL AVE SE, ALBUQUERQUE, NM 87106-4930
(505) 841-1125
(505) 272-0475
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
MD2023-0400
NM
390200000X
Student in an Organized Health Care Education/Training Program
—
NM
Other
Enumeration date
03/29/2019
Last updated
05/02/2023
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