Individual
GARY L. JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
LINCOLN COUNTY MEDICAL CENTER, 211 SUDDERTH, RUIDOSO, NM 88345
(505) 257-8200
(505) 630-4233
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-5356
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
A-903-90
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
41384
—
NM
Enumeration date
03/05/2007
Last updated
08/14/2008
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