Individual
WALLACE J JACKMON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
4400 W 69TH ST, STE 1500, SIOUX FALLS, SD 57108-8170
(605) 322-5700
(605) 322-5704
Mailing address
PO BOX 86370, SIOUX FALLS, SD 57118-6370
(605) 322-7510
(605) 322-6475
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
477
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040537
BLUE CROSS
SD
01
—
040121002
PRIMEWEST
MN
05
—
12200
—
ND
01
—
140M8JA
CC SYSTEMS/ BLUE PLUS
MN
01
—
142415
UCARE
MN
01
—
15096
MIDLANDS CHOICE
SD
01
—
20814
SANFORD HEALTH PLAN
SD
05
—
3989442
—
IA
01
—
412991020844
PREFERRED ONE
SD
05
—
46022474352
—
NE
01
—
57108C003
WPS TRICARE
SD
05
—
6552790
—
SD
05
—
6570753
—
SD
01
—
800013808
RR MEDICARE
SD
01
—
854000
ARAZ/ AMERICA'S PPO
SD
01
—
9205351
DAKOTACARE
SD
05
—
944611700
—
MN
01
—
HP37115
HEALTHPARTNERS
SD
Enumeration date
02/07/2006
Last updated
10/11/2018
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