Individual
WILLIAM JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1441 NE 10TH AVE, PAYETTE, ID 83661-5420
(208) 642-9376
(208) 642-9279
Mailing address
1441 NE 10TH AVE, PAYETTE, ID 83661-5420
(208) 642-9376
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M-14093
ID
207Q00000X
Family Medicine Physician
MD187049
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
M-14093
STATE OF IDAHO MEDICAL LICENSE
ID
01
—
MD187049
STATE OF OREGON, MEDICAL LICENSE
OR
Enumeration date
09/11/2012
Last updated
04/12/2019
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