Individual
RUSSELL PATRICK JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
301 E COTTONWOOD LN STE 1&2, CASA GRANDE, AZ 85122-2551
(602) 569-3999
(520) 340-4359
Mailing address
1753 E CORTEZ DR, CASA GRANDE, AZ 85122-6319
(801) 310-0819
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
8654
AZ
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
08/24/2019
Last updated
09/06/2024
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