Individual
COLTON WORTH JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
8300 CONSTITUTION AVE NE, BLDG D, ALBUQUERQUE, NM 87110-7613
(505) 291-2200
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 412-7467
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA2022-0118
NM
Other
Enumeration date
02/19/2022
Last updated
01/30/2023
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