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Individual

JACOB JACKSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
D.O.

Contact information

Practice address
12266 DE PAUL DR STE 305, BRIDGETON, MO 63044-2514
(314) 770-0991
Mailing address
PO BOX 955534, SAINT LOUIS, MO 63195-5534

Taxonomy

Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
2015012493
MO

Other

Enumeration date
06/26/2013
Last updated
11/10/2020
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