Individual
WALLACE J JACKMON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
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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