Individual
ANN MARIE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
1 MEDICAL CENTER DR RM 1200, MORGANTOWN, WV 26506-1200
(304) 293-6109
Mailing address
971 VALLEY VIEW AVE APT 304, MORGANTOWN, WV 26505-3670
(304) 667-0164
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
4280
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1841271459
WV CHIP
WV
05
—
1841271459
—
WV
Enumeration date
07/12/2017
Last updated
07/12/2017
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